NUTRITION  AND  GROWTH 
IN  CHILDREN 


A   FULL  FACE  DOES  NOT  ALWAYS  INDICATE  A  WELL   .NOURISHED  BODY 


Herbert,  aged  six  and  one-half  years,  is  more  than  Iwo  years  retarded 
in  growth,  liis  round  shoulders,  protruding  shoulder  blades,  pi'ominent 
abdomen,  flabby  muscles,  and  fatigue  postur'e  are  all  siirns  of  malnu- 
trition, but  his  round  face  and  regular  features  make  him  look  well 
nourished  when  di'essed.  Defects:  underweight  16  per  cent  (8  lb.); 
nasopharyngeal  obstruction;  carious  teeih  (two»;  spinal 
curvature  ;  otitis  media  ;   fatigue  posture. 


NUTRITION  AND  GROWTH 
IN  CHILDREN 


!    BY 

WILLIAM  R.  P.  £MERS0N,  A.B.,  M.D. 

PBOFESSOR  or  PEDIATRICS,  TUFTS  COLLEGE   MEDICAL  SCHOOL  ; 
PRESIDENT,    NUTRITION    CLINICS    FOR    DELICATE    CHILDREN, 
incorporated;     medical     adviser,     ELIZABETH     MCCOR- 
MICK  MEMORIAL  FOND,  CHICAGO;  VISITING  PHYSICIAN 
(IN     CHARGE     OF     NUTRITION     CLINIC),     CHILDREN'S 
OUT-PATIENT  DEPARTMENT,   MASSACHUSETTS  GEN- 
ERAL   HOSPITAL,    BOSTON 


ILLUSTRATED 


D.  APPLETON  AND  COMPANY 

NEW  YORK  LONDON 

1922 


\ 


COPYRIGHT,    1932,   BY 

D.  APPLETON  AND  COMPANY 


Copyright,  1919,  1920.  1921.  by 
"Woman's  Home  Companion" 

7KINTED  IN  THI  UNITED  STATES  OF  AUEKICA 


TO 

MY  MOTHER 


PREFACE 

In  1908,  while  in  charge  of  the  Children's  Out- 
Patient  Clinic  in  the  Boston  Dispensary,  I  became 
interested  in  a  number  of  undernourished  children 
who  kept  coming  to  the  dispensary  week  after  week 
and  month  after  month,  passing  from  one  department 
to  another  without  receiving  help.  Their  records 
showed  long  histories  and  repeated  examinations,  yet 
the  most  frequent  diagnoses  were  "Debility"  or  ''No 
disease."  From  the  medical  standpoint  there  was 
nothing  the  matter  with  them,  but  from  the  point  of 
view  of  physical  fitness  there  was  everything  the 
matter  with  them. 

I  formed  a  group  or  class  of  12  of  these  children, 
and  had  them  report  once  a  week  with  the  idea  of 
studying  them  for  the  whole  24-hour  period  to  dis- 
cover if  possible  the  real  cause  of  their  poor  physical 
condition.  In  order  to  visualize  their  progress,  as 
well  as  to  arouse  interest,  I  made  charts  showing  the 
actual  weight  of  the  children  from  week  to  week, 
with  a  comparative  line  representing  what  their 
weight  should  be.  The  mothers  were  invited  to  at- 
tend the  class  and  consulted  as  to  the  possible  cause 
of  failure  to  gain.  Advice  was  then  given  on  any 
point  that  seemed  to  promise  better  results. 

Although  the  majority  of  the  group  showed  some 
signs  of  improvement,  and  an  occasional  child  would 
gain  sufficiently  to  come  up  to  the  average  standard, 

vii 


PREFACE 

many  of  the  children  made  little  or  no  progress,  and 
after  months  of  effort  their  charts  showed  lower  rela- 
tive weights  than  at  the  start. 

So  far  as  I  know,  this  was  the  first  nutrition  class 
ever  organized. 

The  net  results  of  this  experiment  were  the  ideas 
of  class  organization,  the  importance  of  considering 
the  child's  entire  program,  the  advantage  of  visualiz- 
ing his  physical  condition  by  means  of  the  weight 
chart,  and,  perhaps  most  important  of  all,  the  chal- 
lenge that  came  to  me  from  those  patient  and  per- 
sistent mothers  who  were  ready  to  do  all  that  I  asked, 
even  when  rewarded  by  only  slight  evidence  of  prog- 
ress. Such  was  the  interest  of  the  children  and  their 
mothers  that  I  still  have  hundreds  of  charts  from 
these  early  years  which  register  regular  attendance 
for  periods  as  long  as  40  weeks  without  a  relative 
gain  of  a  single  pound. 

Looking  back  through  thirteen  years'  study  of  this 
problem,  I  find  the  following  ideas  to  have  been  con- 
sidered in  turn  as  primary  causes  of  malnutrition, 
only  to  be  discarded  or  relegated  to  a  position  of  sec- 
ondary importance,  one  after  the  other: 

1.  Poverty  and  insufficient  food  supply 

2.  Improperly  cooked  food  and  consequent  indigestion 

3.  Bad  air 

4.  Heredity 

5.  Syphilis 

6.  Tuberculosis 

7.  Self-abuse 

The  study  of  each  of  these  theories  made  some  im- 
portant contribution  to  the  ultimate  development  of 

viii 


PREFACE 

our  present  nutrition  program,  but  the  outcome  was 
in  every  case  different  from  what  I  had  expected,  and 
I  was  obliged  to  enter  upon  a  new  investigation. 

At  the  time  when  I  began  my  studies,  malnutrition 
was  almost  invariably  considered  to  be  a  problem  of 
poverty  and  food,  and  my  approach  to  it  was  from 
this  standpoint.  At  the  first  meeting  of  the  class  of 
mothers  and  children  referred  to,  I  supposed  it  would 
be  necessary  to  see  that  the  families  were  supplied 
with  sufficient  food  and  taught  to  prepare  it  properly. 
I  had  even  gone  so  far  as  to  purchase  a  cook  book  and 
study  it,  so  that  I  could,  if  necessary,  teach  the 
mothers  how  to  prepare  food. 

It  soon  became  clear,  however,  that  although  pov- 
erty is  a  contributing  factor,  it  is  not  the  funda- 
mental cause  of  malnutrition.  Later  investigations 
show  an  even  higher  percentage  among  the  well-to-do 
and  the  rich  than  among  the  children  of  the  poor. 
With  few  exceptions,  the  families  concerned  in  this 
first  study  were  found  to  have  sufficient  food  for  good 
nourishment,  but  the  malnourished  child  had  either 
omitted  certain  essential  foods  from  his  diet  or  else 
had  formed  bad  food  habits. 

Ideal  family  life  requires  provision  for  privacy, 
wholesome  recreation,  and  much  else  that  is  not  easy 
to  secure.  It  is  not  merely  a  question  of  the  bare 
necessities,  but  of  conveniences  and  comforts  as  well. 
Nevertheless,  my  experience  in  the  poorest  sections  of 
our  cities,  with  children  both  in  their  own  homes  and 
in  charity  clinics,  shows  that  ihe  essentials  of  health 
are  attainable  in  the  home  of  practically  every  family. 
More  recent  studies  indicate  that  many  families 
among  the  poor  consume  too  large  a  proportion  of 

ix 


PREFACE 

the  more  expensive  foods,  and  it  is  frequently  pos- 
sible to  teach  a  mother  how  to  care  better  for  her 
family  on  less  money  than  she  has  been  accustomed 
to  spend  for  food. 

The  matter  of  cooking  in  its  bearing  on  the  child's 
nutrition  also  retired  to  a  secondary  position  as  I 
found  that  the  city  mother  does  comparatively  little 
home  cooking.  Hot  bread  and  deep  frying,  which 
produce  much  of  the  indigestion  found  in  more  re- 
mote sections  of  the  country,  are  not  customary  fea- 
tures of  the  diet  of  poor  families  in  the  cities. 
Standardized  bread  and  milk  have  taken  the  control 
of  these  fundamental  foods  away  from  the  home,  and, 
with  the  abundant  supply  of  good  cereals,  a  large 
part  of  the  usual  dietaries  is  thus  established  on  a 
high  plane.  Food  is  important,  but  the  difficulty  is 
usually  in  the  food  habits  of  the  individual  rather 
than  in  the  quantity  available  or  in  the  mode  of 
preparation. 

At  this  time  it  began  to  be  apparent  that  the  fun- 
damental causes  of  malnutrition  are  more  individual 
than  had  been  supposed.  I  had  feared  that  in  many 
homes  a  number  of  children  would  be  found  suffer- 
ing from  this  condition,  but  it  was  a  common  experi- 
ence to  find  one  child  underweight  with  his  sisters  or 
brothers  up  to  the  normal  standard  or  even  over- 
weight. It  was  not  until  1913,  after  I  had  been  giv- 
ing my  main  energies  to  the  problem  for  five  years, 
that  a  family  appeared  in  which  as  many  as  three 
children  were  malnourished,  and  this  family  Avas  in 
fairly  comfortable  circumstances. 

From  this  study  of  the  child's  nutrition  on  an  in- 
dividual basis  came  an  appreciation  of  two  new  fac- 


PREFACE 

tors  of  vital  importance,  namely,  measured  feeding 
and  proper  food  habits.  Prof.  Irving  Fisher's  notable 
article  on  100-calory  portions,  with  the  reports  of 
the  United  States  Department  of  Agriculture,  made 
it  possible  to  work  out  tables  to  determine  the  actual 
food  consumption  of  the  individual.  Measured  feed- 
ing and  careful  observation  of  the  food  habits  of  the 
child  are  now  regular  features  of  our  nutrition  pro- 
gram. 

The  next  subject  specially  considered  was  bad  air, 
particularly  in  relation  to  sleeping  conditions.  This 
was  in  1911,  when  our  first  clinic  was  established  at 
the  Berkeley  Infirmary.  The  Berkeley  window  tent 
was  used  as  a  means  by  which  a  child  could  gain  the 
benefits  of  sleeping  in  the  open  air  while  remaining 
in  his  own  home. 

In  order  to  install  these  tents  it  was  necessary  to 
go  into  the  homes  and  work  out  new  sleeping  ar- 
rangements. This  afforded  an  opportunity  for  con- 
tact with  the  family  in  a  natural  way.  I  have  always 
insisted  that  no  one  has  a  right  to  cross  the  threshold 
of  a  home  except  on  the  invitation  of  the  family,  and 
that  the  privilege  should  not  be  abused  by  an  attempt 
to  discover  the  skeleton  in  the  closet. 

This  step  in  the  investigation  gave  a  glimpse  into 
the  significance  of  home  organization  and  control, 
although  the  particular  line  of  attack  from  which  it 
developed,  the  consideration  of  bad  air,  proved  no 
more  than  poverty  or  badly  prepared  food  to  be  a 
fundamental  cause  of  malnutrition.  The  children 
did  better  under  the  improved  sleeping  conditions, 
but  the  central  problem  was  still  unsolved. 

Heredity  as  an  explanation  of  malnutrition  is  still 
xi 


PREFACE 

a  favorite  hypothesis.  Most  undernourislied  children, 
however,  are  born  of  normal  weight,  and  continue  to 
be  well  and  strong  through  the  period  of  infancy. 
It  is  only  when  they  come  to  the  pre-sch.ool  or  school 
age  that  malnutrition  appears.  This  may  follow  an 
acute  illness,  such  as  measles  or  whooping  cough,  or 
it  may  be  a  gradual  loss  in  weight  which  is  taken  for 
granted  in  the  growing  child.  Here  again  it  is  sig- 
nificant that  where  one  child  may  be  malnourished, 
other  members  of  the  family  may  be  in  good  health. 

When  Wassermann  tests  were  applied  to  groups  of 
malnourished  children,  I  found  the  indication  of 
hereditary  syphilis  to  be  somewhat  greater  than 
among  other  groups,  but  in  no  study  did  it  amount 
to  more  than  four  or  five  per  cent,  and  consequently 
it  cannot  explain  the  widespread  malnutrition. 

Similarly,  the  proportion  of  positive  von  Pirquet 
tests  was  about  the  same  as  that  found  among  chil- 
dren not  suffering  from  malnutrition.  Those  children 
whom  we  thought  might  be  tubercular  gained  in 
weight  as  fast  as  the  others  when  the  real  cause  of 
their  underweight  was  finally  determined. 

There  is  a  general  belief  that  self-abuse  is  a  cause 
to  be  reckoned  with  in  dealing  with  a  debilitated  con- 
dition, but  I  have  not  found  a  single  ease  in  which 
malnutrition  could  be  traced  to  this  source.  This 
experience  coincides  with  that  of  the  neurologists, 
who  rarely,  if  ever,  find  self-abuse  a  cause  of  either 
mental  derangement  or  poor  physical  condition.  It 
is  a  common  symptom  of  mental  deficiency,  but  in 
every  case  of  normal  mentality  in  my  experience  the 
practice  has  been  due  to  local  irritation  caused  by  a 
pyelitis,  cystitis,  or  other  inflammatory  condition. 

xii 


PREFACE 

It  was  somewhat  disconcertiug  after  a  thorough 
study  of  these  usually  assigned  causes  of  malnutri- 
tion to  find  the  problem  still  unsolved.  Difficult  as 
it  was  to  disabuse  my  mind  of  these  ideas,  I  decided 
to  study  the  children  as  I  found  them,  to  utilize  every 
possible  means,  medical,  physical,  social  or  psycho- 
logical, to  get  each  child  well,  and  to  seek  with  open 
mind  the  cause  of  his  malnutrition.  This  point  of 
view  led  to  a  new  outlook  and  to  an  entire  recon- 
struction of  values. 

Medical  social  service  was  at  this  time  in  a  state 
of  agitation  and  unrest,  and  it  was  difficult  to  make 
progress  because  the  trained  worker,  like  the  physi- 
cian, was  prepossessed  with  ideas  which  experience 
had  shown  me  were  not  valid.  During  the  earlier 
years  of  my  experiments  I  was  fortunate  in  having 
the  assistance  of  Miss  Ruth  L.  Greeley,  a  faithful  and 
devoted  volunteer  worker.  Since  1912  Miss  Mabel 
Skilton  has  been  associated  with  me  in  this  work,  and 
her  untiring  interest  and  personal  work  with  both 
mother  and  child  have  been  of  the  greatest  value  in 
the  development  of  the  nutrition  class. 

The  results  of  earlier  studies  which  continued  ex- 
perience had  by  this  time  brought  into  clearer  defini- 
tion as  of  vital  importance  were  home  control,  food 
habits,  and  health  habits.  Two  new  factors  now 
claimed  attention,  namely,  physical  defects,  particu- 
larly obstructions  to  breathing,  and  overfatigue. 
These  five  factors  form  the  basis  of  our  present  nutri- 
tion program  and  have  proved  to  be  fundamental 
ideas  to  be  considered  in  the  care  of  the  growing 
child. 

As  these  ideas  were  formulated  into  a  definite  nutri- 
N  xiii 


PREFACE 

tion  program,  our  work  attracted  attention  in  other 
cities.  Among  the  visitors  to  our  clinics  in  1916  was 
Mr.  Frank  A.  Manny,  representing  the  New  York 
Association  for  Improving  the  Condition  of  the  Poor. 
This  society,  after  an  honorable  record  of  three- 
quarters  of  a  century  spent  in  wrestling  with  the 
problems  of  poverty  and  disease,  had  undertaken 
under  Mr,  Manny's  direction  a  study  of  the  causes 
and  treatment  of  malnutrition.  Arrangements  were 
made  for  presenting  our  program  at  the  Academy  of 
Medicine,  and  the  workers  in  a  number  of  child- 
helping  organizations  cooperating  with  Mr.  Manny 
came  to  Boston  for  advice  and  training.  Clinics  and 
classes  were  established  in  this  connection  at  Bellevue 
Hospital,  Cornell  Medical  School,  Bowling  Green 
Neighborhood  Association,  Post-Graduate  Hospital, 
and  with  a  number  of  the  activities  that  later  crys- 
tallized into  various  national  organizations  for  child 
health. 

I  had  long  felt  that  the  proper  place  to  deal  ade- 
quately with  malnutrition  was  in  the  public  school, 
where  it  would  be  possible  to  reach  practically  all  the 
children  in  the  community.  I  was  glad,  therefore,  to 
accept  an  invitation  from  the  Bureau  of  Educational 
Experiments  to  supervise  an  experimental  study  on 
the  East  Side  of  New  York  City. 

Work  was  accordingly  undertaken  in  1918  in  Pub- 
lic School  64  and  carried  on  for  a  period  of  19  weeks. 
This  school  had  a  very  conservative  program,  and  in 
adjusting  our  nutrition  classes  to  the  school  schedule 
many  compromises  were  necessary.  Although  it  was 
a  war  year  and  the  cost  of  food  seemed  to  offer  ex- 
traordinary  difficulties,  it  was   nevertheless  demon- 

xiv 


PREFACE 

strated  in  this  experiment  that,  with  slight  modifica- 
tion of  their  day's  program,  the  malnourished  chil- 
dren could  be  made  well  in  their  own  homes.  The 
gains  made  varied  from  100  to  200  per  cent  of  the 
expected  rate  of  growth  for  normal  children. 

To  meet  the  growing  demands  from  various  sections 
of  the  country,  a  national  organization,  Nutrition 
Clinics  for  Delicate  Children,  Incorporated,  was 
formed  in  1919.  The  requests  for  special  training 
have  led  to  the  holding  of  institutes  twice  a  year  in 
both  Boston  and  Chicago,  in  which  physicians,  re- 
search students,  nurses,  social  workers,  dietitians, 
charity  workers,  teachers  and  other  experienced  per- 
sons have  been  given  intensive  instruction  and  dem- 
onstrations of  nutrition  clinics  and  classes. 

Clinics  and  classes  have  been  established  in  the 
meantime  at  the  Massachusetts  General  Hospital,  the 
Little  Wanderers'  Home,  various  neighborhood  set- 
tlements, the  Farm  Home  of  the  Boston  Fathers  and 
Mothers  Club,  and  in  connection  with  the  Boston  Tu- 
berculosis Association.  Each  of  these  organizations 
represents  a  distinct  type  of  need,  and  in  each  we 
have  been  able  to  demonstrate  that  malnourished 
children  can  be  made  well  by  means  of  a  simple  nu- 
trition program. 

Through  an  address  delivered  in  Washington  at  the 
Intei*national  Child  Welfare  Conference  in  May, 
1919,  our  work  came  to  the  attention  of  Mrs.  Ira 
Couch  Wood,  director  of  the  Elizabeth  McCormick 
Memorial  Fund,  Chicago.  After  a  thorough  test  our 
nutrition  program  has  since  been  adopted  by  Mrs. 
Wood  as  the  basis  of  the  work  of  that  organization, 
which  reaches  not  only  the  home  city  and  state,  but 

XV 


PREFACE 

also  influences  cMld-welfare  work  throughout  the 
West.  The  office  of  the  Fund  has  now  become  the 
Western  headquarters  of  our  society,  and  under  itvS 
auspices  five  institutes  have  already  been  held,  in- 
cluding in  their  membership  representatives  of  nearly 
all  the  Western  states. 

The  first  comprehensive  community  program  de- 
veloped in  1919  in  Walpole,  Massachusetts,  where  the 
school  authorities  sought  our  cooperation  in  eliminat- 
ing malnutrition.  All  the  children  in  the  public 
schools  of  that  town  have  been  weighed  and  meas- 
ured, and  nutrition  classes  have  been  formed  for  those 
found  to  be  seven  or  more  per  cent  underweight. 

An  institute  held  in  Atlanta  under  the  auspices  of 
the  American  Red  Cross  in  May,  1920,  was  attended 
by  50  members,  including  representatives  of  the 
United  States  Department  of  Agriculture  from  prac- 
tically all  the  Southern  states.  Summer  sessions 
were  held  in  June,  1920  and  1921,  at  the  School  of 
Education  in  Cleveland,  where  an  affiliated  organiza- 
tion carries  on  the  work.  In  November,  1920,  the 
Tuberculosis  Association  acting  with  other  child-help- 
ing organizations  united  in  an  institute  of  over  a  hun- 
dred members,  including  22  physicians,  at  Rochester, 
New  York. 

More  recently  a  largely  attended  institute  has  been 
held  at  Grand  Rapids,  Michigan,  under  the  auspices 
of  a  ehild-health  association  organized  for  the  pur- 
pose, and  a  state-wide  movement  has  been  inaugurated 
in  New  Hampshire  after  an  institute  that  was  at- 
tended by  representatives  from  62  cities  and  towns. 
The  nutrition  movement  has  been  extended  to  an  older 

xvi 


PREFACE 

group  in  this  state  by  the  inauguration  of  classes  for 
the  students  at  Dartmouth  College. 

Public  addresses  have  been  made  all  the  way  from 
New  Hampshire  on  the  east  to  California  and  the 
Hawaiian  Islands  on  the  west  and  as  far  south  as 
Georgia.  During  the  summer  of  1920  two  of  our 
trained  workers  organized  classes  in  Labrador  in  con- 
nection with  the  work  of  Dr.  Grjenfell,  and  their  work 
was  extended  in  1921. 

This  brief  sketch  of  the  stages  through  which  our 
work  has  passed  is  given  to  show  the  various  aspects 
of  the  problem  presented  by  the  malnourished  child, 
who  in  the  past  has  been  considered  neither  sick  nor 
well.  Difficulties  have  been  met  with,  and  must  still 
be  overcome  in  many  places  before  the  subject  re- 
ceives the  attention  which  its  importance  deserves. 
Among  these  may  be  mentioned  the  following: 

1.  Malnutrition  is  a  very  old  subject,  and  the  ideas 
and  theories  held  about  it  have  frequently  emanated 
from  men  working  behind  desks  rather  than  from 
those  in  direct  contact  with  the  children  needing 
help. 

2.  Nutrition  work  is  a  form  of  preventive  medi- 
cine, all  branches  of  which  have  thus  far  attracted 
too  little  attention. 

3.  The  laboratory  field,  where  results  can  be  meas- 
ured by  chemical  reactions  and  the  microscope,  has 
been  more  alluring  to  the  research  worker  than  clinical 
work  with  such  a  difficult  and  uncertain  factor  as  the 
children  themselves. 

4.  On  the  medical  side  there  have  been  practically 

xvii 


PREFACE 

no  studies  of  the  subject,  and  the  physician  has  been 
almost  as  ready  as  the  layman  to  accept  ideas  put 
forward  without  foundation  or  justification.  As  a 
result  little  help  has  come  from  the  quarter  that 
ought  to  aid  the  most.  Progress  will  be  delayed  until 
fundamental  work  in  nutrition  is  an  established  part 
of  the  training  of  the  physician.  At  present  the  field 
is  almost  untouched  in  either  medical  school  or  hos- 
pital. 

5.  Although  the  problem  is  fundamentally  medical, 
it  is  also  largely  educational,  touching  the  most  inti- 
mate human  experiences — the  habits  and  prejudices 
of  a  lifetime  in  both  parent  and  child. 

6.  The  malnourished  child  is  not  considered  sick 
as  long  as  he  is  able  to  be  on  his  feet.  Even  to  the 
average  physician  there  is  nothing  urgent  in  his  need. 
In  the  schools  there  are  so  many  of  these  unfortunate 
children,  from  one-fourth  to  one-third  of  all,  that  the 
teachers  have  become  accustomed  to  attempting  to 
force  them  through  the  grades  in  order  to  maintain 
the  school's  supposed  efficiency,  whereas  in  reality 
their  condition  is  a  constant  occasion  for  lowering 
standards. 

7.  The  program  of  nutrition  clinics  and  classes 
meets  the  opposition  of  many  organizations  that  do 
not  willingly  relinquish  the  ideas  upon  which  their 
work  is  founded. 

The  spread  of  these  ideas  would  necessarily  have 
been  much  slower  had  it  not  been  for  the  startling 
revelations  of  the  selective  service  draft.  The  report 
of  the  Surgeon-General  of  the  Army,  which  showed 
barely  50  per  cent  of  our  young  men  physically  fit 

xviii 


PREFACE 

for  service  in  the  first  line,  was  a  shock  to  medical 
men,  economists,  educators,  and  the  general  public. 
The  fact  that  this  condition  was  largely  due  to  de- 
fects and  habits  that  are  remediable  in  childhood  has 
focussed  attention  upon  the  problem  of  these  early 
years.  It  is  in  the  hope  that  a  wider  knowledge  of 
our  nutrition  program  may  help  to  correct  this  con- 
dition that  this  book  on  Nutrition  and  Growth  in 
Children  is  written. 

I  wish  to  express  my  deep  personal  appreciation  of 
the  helpfulness  of  Mr.  Frank  A.  Manny  in  preparing 
these  pages,  especially  the  statistical  work;  of  Mrs. 
Katharine  Maynard  in  rearranging  and  revising  the 
text  and  in  making  the  glossary  and  index;  and  of 
Miss  Marion  Dickson  in  the  making  of  charts.  I  wish 
also  to  acknowledge  again  the  assistance  received  from 
Miss  Mabel  Skilton  in  working  out  these  nutrition 
problems,  and  the  cooperation  of  many  others 
throughout  the  country  who  have  borne  an  impor- 
tant part  in  extending  the  work. 

William  R.  P.  Emerson 


XIX 


CONTENTS 


PAGU 

Preface vii 


PART  I 
THE  DIAGNOSIS  OF  MALNUTRITION 

CHiPTER 

I.    Malnutrition  and  Growth        ...  3 

II.    How    to    Identify    the    Malnourished 

Child 12 

Weight  Standards 12 

Weiglit  Tables 13 

The  Maluourisbed 14 

Borderline  Cases 16 

Ideal   Weight 17 

The  Overweight 19 

How  to  Weigh  and  Measure     ...  19 

III.  The  Case  History 21 

The  Family  History 22 

Birth  and  Infancy 22 

Previons  Diseases 23 

General  Health  and  Habits       ...  23 

Present  Symptoms 24 

IV.  The  Physical-Growth  Examination      .  25 

Physical  Signs 28 

Naso-Pbai"yngeal  Obstruction   ...  29 

Teeth  Defects 31 

Medical  Defects 32 

Defects  at  Various  Ages  ....  34 

The  Examination  Form      ....  35 

"Before"  and  "After"  Pictures        .       .  41 

V.   The  Mental  Examination  ....  43 


CONTENTS 

CHAPTBB                                                                                                                    FAOB 

yi.   The  Social  Examination    ....      51 

The  48-bour  Record    . 

52 

Overfatigue 

54 

Home  Conditions 

55 

Food  Habits 

55 

Health  Habits     . 

.       55 

The  New  Program 

5G 

Foster  Homes 

57 

Summary  of  a  Social  Investigatior 

I 

58 

PART  II 
MALNUTRITION  AND  THE  HOME 

VII.    The  Essentials  of  Health        ...  63 

The  Home G6 

The  School 66 

Medical  Care 67 

The  Child's  Own  Interest  ....  68 

VIII.   Home  Control 69 

Training  for  Health 70 

Winning  the  Child's  Confidence       .        .  71 
The  Correction  of  Bad  Sex  Habits       .  72 
Selfishness  in  Parents  and  Children        .  73 
The  Influence  of  Suggestion  and  Compe- 
tition            75 

Punishment  Should  be  Constructive       ,  77 

Responsibility  of  the  Parents  ...  78 

IX.    Overfatigue 80 

Fatigue  and  Overfatigue   ....  80 

Causes  of  Overfatigue       ....  81 

Rest  and  Sleep 83 

The  Strain  of  School  Life        ...  86 

Outside  Studies  and  Clubs        ...  87 

X.   Measured  Feeding 89 

Food  Values 90 

A  Food  Exhibit 92 

A  Diet  Record 92 

How  to  Make  Changes  in  the  Diet  .        .  95 

An  Aid  to  Diagnosis 97 

xxii 


CONTENTS 

SAFTEB  FAOa 

Increasing  the  24-Hour  Amount     .        .  97 

The  Amount  of  Food  Needed  ...  98 

XI.   Diet  and  Food  Habits        ....  107 

The  Balanced  Diet 109 

Essential  Foods 110 

Sweets           114 

Liquids  and  Mastication    ....  114 

Fast  Eating 116 

The  Family  Table 116 

Loss  of  Appetite,  Its  Cause  and  Its  Cure  117 

Food  Aversions 119 

XII.    Health  Habits 123 

Fresh  Air 124 

Drugs  Unnecessary 12S 

Care  of  the  Teeth 130 

The  Right  Kind  of  Clothing     .        .        .130 

Bathing 132 

Habits  and  Health 133 

XIII.  Exercise  and  Recreation    ....  134 

Training  in  Play 134 

The  Need  of  Moderation   .        .        .        .  135 

Corrective  Exercises 137 

Indoor  Amusements 138 

A  Health  Program  for  Summer       .       .  138 

The  Benefits  of  the  Summer  Camp       .  140 

Athletics  for  the  Older  Boy  and  Girl     .  142 

Health  in  Industry  and  Business   .       .  144 

XIV.  The  Pre-School  Child        .       .       .       .146 

XV.    The  Overweight  Child       ....  155 

"What  Constitutes  Oveinveight?       .        .  155 
Comparison  of  Overweight  and  Under- 
weight    Children     with     Respect     to 

Physical  Defects 156 

Danger  of  Overweight       ....  158 

The  Cause  of  Overweight  ....  159 

The  Remedy  for  Ovenveight     .       .       .  159 

Influence  of  Heredity         ....  161 

XVI.   Questions  Commonly  Asked     .       .       .  164 
zxiii 


CONTENTS 


PART  III 

A  NUTRITION  PROGRAM  FOR  THE 
COMMUNITY 


CHAPTER 

XVII. 


PAOB 

The  Nutrition  Class 183 

Class  Orgranization 184 

Class  Procedure 186 

Food  and  Rest 188 

Results  Secured 189 

Summary 191 


XVIII. 


193 

195 
196 
197 
198 


The  Nutrition  Worker       .... 
The  Nutrition  Worker  and  the  Physician 

Visitors 

A  Social  Diagnostician      .       .       .       . 

Home  Visits 

Family  Types 201 

Interest  in  Children 204 

The  Appeal  of  Nutrition  Work       .       .     205 

XIX.   The  Physician  and  the  Nutrition  Class    207 

XX.   Report  of  a  Class  Meeting       .       .       .     215 


School 


XXI.    The  Nutrition  or  Diagnostic  Clinic 

XXII.   Malnutrition  and  the  School 
Efifect  of  Malnutrition 
Extent  of  Malnutrition 
The  Nutrition  Program  in  the 
The  School  Physician 
The  Nutrition  Clinic  . 
School  Hours 

Adjustment  of  the  Schedule 
Adjustment  of  the  Program 
Health  Education 


222 

228 

228 
230 
230 
233 
233 
234 
235 
238 
239 


XXIII.    School     Lunches     for     Malnourished 

Children 241 


A  Comparative  Study 
Unfavorable  Conditions 
An  Educational  Opportunity 
Obstacles  to  Progress 
xxiv 


244 
244 
245 
246 


CONTENTS 

CHAPTER  PAGE 

XXIV.   Institutions  and  the  Summer  Camp     .  249 

Foster  Homes 250 

Correctional  Institutions  ....  252 

Summer  Camps 252 

XXV.   Malnutrition  and  the  Community  .       .  256 

Nutrition  Classes  in  the  Schools     .       .  257 

Nutrition  Clinics  for  Problem  Cases       .  258 

Extension   Service 260 

Outline  of  a  Community  Program        .  262 

XXVI.   Malnutrition  and  Tuberculosis       .       .  266 

XXVII.    Malnutrition  and  Preventive  Medicine  273 

The  Nutrition  Program  and  Prevention  274 

Effect  of  Wrong  Ideas     ....  276 

Health  Education  and  Prevention   .       .  279 

XXVIII.    The  Extent  of  Malnutrition  and  Some 

Results  of  Nutrition  Work     .       .  282 


APPENDICES 

I.    Tables  of  Weights       .....  305 

II.   Forms  for  Nutrition  Records  .       .       .  311 

III.  Glossary 326 

IV.  List    of     Publications     of     Nutrition 

Clinics  for  Delicate  Children,  In- 
corporated        331 


zsv 


ILLUSTRATIONS 

A  Full  Face  Does  Not  Always  Indicate  a  Well 

Nourished  Body         ....      Frontispiece 

nOUBS  PAOB 

1.  A  Large  Initial  Gain 7 

2.  Underweight  and  Underheight         ....  9 

3.  How  to  Measure facing  16 

4.  A  Gain  of  31  Pounds  in  21  Weeks       ...  18 

5.  Malnutrition  and  Obesity   in  the   Same  Family 

facing  20 

6.  Complete  Examination 26 

7.  A  Typical  Malnourished  Child        .       .        facing  28 

8.  Effect  of  Adenoid  and  Tonsil  Operations     .       .  30 

9.  Deformity  and  Malnutrition    .        .        .        facing  34 

10.  Six  Malnourished  Girls    ....        facing     40 

11.  Mental  Retardation  or  Mental  Deficiency     facing    44 

12.  Heredity  is  Not  Usually  the  Cause  of  Malnutri- 

tion         facing     52 

13.  An  Unhappy  Home 57 

14.  The  Parallelogram  of  Forces  that  Safeguard  the 

Child's  Health 04 

15.  A  Difference  of  Five  Years  in  Age  and  of  Four 

Pounds  in   Weight    ....        facing     70 

16.  Rest  Positions facing     84 

17.  Food  Exhibit  of  Hundred-Calory  Portions  facing     92 

18.  Insufficient  Food— Thin  Soup        ....       94 

19.  Cereal  Omitted Ill 

20.  Candy  Habit 113 

21.  Fast  Eating 115 

22.  Bad  Air 125 

xxvii 


ILLUSTRATIONS 

riOUR«  PAGB 

23.  A  So-Called  "Pre-Tubereular"  Child     .       .     126-127 

24.  Gain  at  a  Girls'  Camp      ......     141 

25.  An  Overweight  Girl facing  160 

26.  The  Case  of  Louise  .......     162 

27.  The  Case  of  Dorothea,  Before  Treatment      facing  184 

28.  The  Case  of  Dorothea 185 

29.  The  Case  of  Dorothea,  After  Treatment      facing  186 

30.  A  Nutrition  Class  in  Session  .        .        .        facing  188 

31.  Nutrition  Class  Diploma 190 

32.  The  Child  as  an  Object  Lesson       .        .        facing  210 

33.  School  Hours  Reduced 217 

34.  A  Case  of  Cardiospasm  ....        facing  224 

35.  School  Examinations 231 

36.  School  Half  Day 236 

37.  The  Value  of  Lunches 243 

38.  Underweight  Children  are  Unfit  for  Work    facing  254 

39.  Continued  Gain  After  Entering  Industry    .        .     260 

40.  An  Early  Chart:  No  Gain 288 

41.  Nutrition  Class  and  Diet  Classes  Compared         .     289 

42.  A  1918  Class  at  the  Berkeley  Infirmary,  Boston     290 

43.  Classes  in  the  Francis  W.  Parker  School,  Chi- 

cago, 1920 291 

44.  Group  Gain  at  a  Nutrition  Camp  in  Grand  Rap- 

ids, Michigan,  1920-21 292 


XXVIU 


ILLUSTKATIONS 
FORMS 

PAGE 

I.  Index  Record  Card 311 

II.  Front  and  Back  of  White  Classification  Card  312 

III.  Front  and  Back  of  Blue  Classification  Card    .  313 

IV.  Front  and  Back  of  Red  Classification  Card     .  314 
V.  Front  and  Back  of  Slate  Classification  Card  .  315 

VI.  Nutrition  Record  Card,  Buff      .       .       .       .316 

VII.  Front  and  Back  of  Individual  Weight  Chart  .     317 

VIII.  Weight  Chart  for  Use  in  Nutrition  Classes     .     31S 

IX.  Front    and    Back    of   History    and    Physical 

Examination  Form       .       .        .        facing  320 

X.  Registration  and  Visible  Record  Form     ,        .     321 

XI.  Foi-tnightly  Report  of  Nutrition  Class     .    322,  323 

XII.  Quarterly  Report  of  Nutrition  Class       .    324,  325 


ZXIX 


PAET  I 

THE  DIAGNOSIS 
OF  MALNUTRITION 


NUTRITION  AND   GROWTH 
IN   CHILDREN 

CHAPTER  I 

MALNUTRITION  AND  GROWTH 

The  care  and  feeding  of  infants  has  become 
not  only  a  science,  but  an  art.  Accurate  studies 
have  been  made  as  regards  food  constituents, 
measured  feeding,  hygiene,  and  every  detail  of 
growth  and  development.  After  the  age  of  two, 
however,  the  physical  condition  of  the  growing 
child  receives  little  consideration  by  either 
physician  or  parent  except  in  actual  illness. 

Although  this  is  a  most  important  time  for 
the  child 's  nutrition  and  growth,  little  is  done  to 
make  sure  that  he  will  pass  through  these  years 
safely,  and  reach  maturity  physically  and  men- 
tally sound.  Food  and  health  habits  are  formed 
during  this  period,  and  it  may  be  said  with  a 
fair  degree  of  certainty  that  if  good  health  is 
established  at  this  time  it  will  continue  through- 
out the  years  of  adult  life. 

At  least  a  third  of  all  children  in  this  country 
are-  underweight  for  their  height,  undernour- 

3 


NUTRITION  AND  GROWTH  IN  CHILDREN 

ished,  and  malnourished.  This  condition  is 
found  alike  on  the  East  Side  of  New  York, 
among  the  well-to-do  in  such  cities  as  Boston 
and  Chicago,  and  in  all  classes  of  society,  as 
shown  in  a  series  of  investigations  extending 
from  Labrador  to  Atlanta. 

A  similar  situation  was  disclosed  by  the  ex- 
aminations for  the  Army,  where  approximately 
the  same  proportion  of  recruits  was  found  unfit 
for  military  service  because  of  conditions 
largely  due,  directly  or  indirectly,  to  malnutri- 
tion. Had  the  causes  of  malnutrition  been  gen- 
erally understood  during  the  childhood  of  these 
recruits,  this  physical  unfitness  could  have  been 
almost  wholly  prevented  by  the  adoption  of  a 
simple  program  insuring  normal  healthy 
growth. 

The  five  chief  causes  of  malnutrition,  in  the 
order  of  their  importance,  are : 

1.  Physical  defects,  especially  naso-pharyngeal  ob- 
structions 

2.  Lack  of  home  control 

3.  Overfatigue 

4.  Improper  diet  and  faulty  food  habits 

5.  Faulty  health  habits 

The  requisites  for  good  health  in  the  growing 
child  are  few — good  air,  simple  food,  rest,  and 
proper  exercise.    If  the  causes  of  malnutrition 

4 


MALNUTRITION  AND  GROWTH 

are  removed,  and  these  simple  requisites  for 
growth  obtained,  we  have  what  may  be  called 
the  essentials  of  health.    These  essentials  are: 

1.  The  removal  of  physical  defects 

2.  Sufficient  home  control  to  insure  good  food  and 
health  habits 

3.  The  prevention  of  overfatigue 

4.  Proper  food  at  regular  and  sufficiently  frequent 
intervals 

5.  Fresh  air  by  day  and  by  night 

With  proper  planning  these  conditions  can 
be  brought  about  in  the  majority  of  families, 
and,  as  a  result,  the  malnourished  child  can  be 
made  well  in  his  own  home. 

Why,  then,  has  malnutrition,  as  a  definite 
condition  with  definite  causes  and  effects,  been 
so  generally  overlooked? 

In  the  first  place,  no  effective  steps  have  been 
taken  by  the  medical  profession,  by  hospitals, 
or  by  the  schools  to  examine  children  for  this 
particular  condition,  and  thus  identify  the  mal- 
nourished group.  Until  the  World  War  fo- 
cused attention  upon  physical  unfitness,  mal- 
nutrition was  not  generally  known  to  be  a 
serious  matter. 

Moreover,  there  has  been  a  general  misunder- 
standing of  the  causes  of  malnutrition.  Phy- 
sicians, educators,  and  social  workers  have  ac- 

5 


NUTRITION  AND  GROWTH  IN  CHILDREN 

cepted,  almost  without  question,  the  theory  that 
this  condition  is  due  mainly  to  poverty  and  im- 
proper food.  Investigation  shows  clearly  that 
these  causes,  as  well  as  many  others  commonly 
proposed,  such  as  bad  air,  heredity,  syphilis, 
and  tuberculosis,  are  of  secondary,  rather  than 
of  primary,  importance. 

A  third  explanation  is  that  parents  and  phy- 
sicians are  so  accustomed  to  the  condition  that 
they  pay  little  or  no  attention  to  it.  Because 
a  child  is  not  sick  in  bed,  and  shows  no  acute 
symptoms,  he  is  considered  well  and  so  treated. 
If  he  falls  behind  in  his  studies,  pressure  at 
home  and  school  is  increased.  If  he  fails,  he  is 
called  lazy.  Thus  a  vicious  circle  is  established 
that  only  adds  to  the  degree  of  his  malnutri- 
tion. It  is  from  the  ranks  of  such  cases  that  the 
misfits  and  failures,  the  physical  and  nervous 
wrecks,  who  make  life  miserable  for  themselves 
and  for  others,  are  later  recruited. 

Malnutrition  is  a  clinical  entity  with  charac- 
teristic history,  definite  symptoms,  and  patho- 
logical physical  signs.  The  malnourished  child 
is  a  sick  child,  and  should  be  so  considered.  In 
the  child's  history  it  is  found  that  malnutrition 
results  from  physical  defects  or  acute  illness, 
or  comes  on  as  a  consequence  of  overfatigue 
or  faulty  habits  in  regard  to  food  or  health. 

6 


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FiGCRE    1.      A   LARGE   INITIAL   GAIN 

Janet  D.,  aged  six  years,  was  30  per  c-ont  underweight,  and  gained 
15  pounds  in  5  weeks.  Ni)tice  tlae  initial  gain  of  6  pounds  la  one 
weeii,  and  the  gradually  smaller  increases  as  she  approached  aver- 
age weight.  The  gain  continued  until  she  was  5  per  cent  above  the 
average   fur   her  height,   clinically   her  normal  weight. 


NUTRITION  AND  GROWTH  IN  CHILDREN 

The  child  becomes  irritable,  tires  easily,  lacks 
physical  and  mental  endurance,  and  exhibits 
other  indications  of  an  unstable  nervous  condi- 
tion. 

Among  the  physical  signs,  besides  under- 
weight, are  lines  under  the  eyes;  anxious  ex- 
pression; pallor;  mouth-breathing  and  other  in- 
dications of  naso-pharyngeal  obstruction;  the 
anterior  cervical  glands  are  frequently  en- 
larged; there  may  be  fatigue  posture,  round 
shoulders,  lateral  curvature,  flat  chest,  rigid 
spine,  ptosis,  prominent  abdomen,  and  pronated 
or  flat  feet.  By  fatigue  posture  is  meant  an  ap- 
pearance similar  to  the  stoop  that  results 
from  muscular  weakness  in  old  age. 

As  the  child  approaches  normal  weight  there 
is  likewise  clinical  evidence  of  a  transformation 
that  is  both  physical  and  mental.  There  is  a 
return  of  color  and  a  glow  of  health  that  is  un- 
mistakable. Normal  reactions  appear,  rest- 
lessness and  irritability  diminish,  and  the  child 
becomes  less  "finicky"  and  "nervous."  Par- 
ents state  that  the  patient  "has  become  a  dif- 
ferent child." 

When  physical  conditions  have  been  corrected 
in  a  malnourished  child,  and  he  is  in  the  condi- 
tion which  we  designate  as  ' '  free  to  gain, ' '  na- 
ture giv€s  a  strong  initial  impetus  to  his  de- 

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Figure  2.    underweight  and  underheight 

Paul  L.,  nine  years  old,  was  40  Inches  tall  and  weighed  47  pounds. 
He  should  have  weighed  53  pounds,  and  was  therefore  8  pounds, 
or  14  per  cent,  underweight  for  his  heijjht.  The  loss  of  weight 
shown  during  the  first  week  occurred  while  he  was  having  dental 
work  done.  Following  this  there  was  a  steady  gain  until  he 
reached  the  average  weight  for  a  lx)y  49  inches  tall,  as  shown  at 
the  average  weight  line.  During  these  12  weeks,  however,  he  had 
grown  in  height  at  twice  the  average  rate,  and  required  4  pounds 
additional  (as  shown  at  the  dotted  line)  to  meet  the  average 
weight  for  his  new  height — evidence  that  he  had  been  stunted.  A 
similar  acceleration  oi  growth  in  height  accompanies  gain  In 
weight  in  nearly  every  Instance  when  the  child  has 
been  habitually  underweight. 


NUTRITION  AND  GROWTH  IN  CHILDREN 

velopment.  This  is  evidenced  by  a  rapid  ad- 
vance in  weight,  the  rate  of  which  is  gradually 
reduced  as  he  approaches  normal  condition. 
During  the  increase  in  weight  there  is  usually 
an  increase  in  height  also.  This  growth  in 
height  is  more  rapid  than  the  rate  made  by  the 
normal  child — a  sudden  compensation  for  re- 
tardation resulting  from  the  removal  of  the 
causes  that  had  been  stunting  growth.  (See 
Figure  2.) 

Wlien  parents  are  awakened  to  the  dangers 
of  malnutrition  their  first  thought  is  apt  to  be 
to  take  the  child  to  some  more  favorable  cli- 
mate, but  they  usually  return  with  little  evi- 
dence of  progress  unless  the  fundamental  cause 
of  the  child's  condition  has  been  discovered  and 
removed.  Study  and  treatment  of  these  mal- 
nourished children  in  nutrition  classes  have 
sho^vn,  almost  without  exception,  that  the  real 
causes  of  malnutrition  can  be  found.  When 
these  causes  have  been  removed,  the  child  re- 
sponds to  the  strong  force  in  nature  that  makes 
for  recovery,  and  returns  to  health  in  a  remark- 
ably short  period  of  time. 

The  nutrition  program  adopted  to  secure 
these  results  has  the  following  distinctive  fea- 
tures, which  are  separately  described  in  the  suc- 
ceeding chapters; 

10 


MALNUTRITION  AND  GROWTH 

1.  Weighing  and  measuring  as  a  means  of  identifi- 
cation 

2.  Diagnosis  based  on  complete  physical-growth, 
mental,  and  social  examinations 

3.  Removal  of  physical  defects  as  a  prerequisite 
for  successful  treatment 

4.  Measured  feeding     (48-liour  diet  record) 

5.  Mid-morning  and  mid-ai'ternoon  lunches 

6.  Mid-morning  and  mid-afternoon  rest  periods 

7.  Regulation  of  physical,  mental,  and  social 
activities  to  prevent  overfatigue  (48-hour  list  of 
activities) 

8.  Nutrition  classes  for  the  treatment  of  malnutri- 
tion 

9.  Nutrition  or  diagnostic  clinics  for  problem  cases 


CHAPTER  n 

HOW  TO   IDENTIFY   THE   MALNOURISHED  CHILD 

As  in  the  treatment  and  care  of  infants  a 
steady  advance  in  weight  is  one  of  the  most  re- 
liable tests  of  good  physical  condition,  so  also 
throughout  childhood  the  weight  curve  con- 
tinues to  be  the  surest  indication  of  proper 
growth.  Unless  he  is  regularly  weighed  the 
child  may  fail  to  gain  for  years  without  its 
being  noticed.  For  this  reason  all  children 
should  be  weighed  once  a  month.  In  a  normal 
child  loss  in  weight  may  be  an  early  indication 
of  illness ;  in  an  undernourished  child  failure  to 
gain  means  that  conditions  are  unfavorable  to 
growth  and  should  be  corrected. 

Weight  Standards. — The  tables  in  general  use 
in  the  past  have  taken  age  as  the  basis  on  which 
to  compute  normal  weight.  But  the  attempt  to 
apply  this  weight  for  age  standard  leads  to 
practical  difficulties  at  once  because  of  the  great 
variation  among  children  of  the  same  age.  It 
also  tends  to  discourage  many  who  find  the 
average  weight  for  their  age  far  beyond  their 
reach.    The  basis  of  height  for  age  is  even  more 

12 


IDENTIFYING  THE  MALNOURISHED  CHILD 

perplexing  because  of  the  large  number  of 
children  who  are  above  the  average  height  for 
their  years. 

After  long  experimentation  with  these  un- 
satisfactory standards,  the  basis  of  weight  for 
height  has  proved  to  be  an  accurate  measure  of 
the  condition  of  undernourished  children,  and 
in  the  many  thousand  cases  that  have  come  un- 
der my  observation  I  have  never  found  an  in- 
stance in  which  it  has  proved  to  be  impracti- 
cable. It  may  be  stated  as  a  physiological  prin- 
ciple that  a  body  of  a  certain  height  requires  a 
certain  weight  to  sustain  it,  and  the  most  signifi- 
cant test  of  a  child's  physical  condition  is  the 
relation  between  his  weight  and  his  height. 

Weight  Tables. — Although  the  weight  for 
height  principle  served  as  a  remarkably  satisfac- 
tory measure  of  the  degree  of  malnutrition,  the 
figures  given  in  the  accepted  tables  were  soon 
found  by  clinical  evidence  to  be  too  low.^  After 
reaching  the  average  weight  for  his  height 
many  a  child  showed  by  his  general  appear- 
ance, poor  color,  and  nervous  condition  that  he 
was  still  below  his  normal  standard.  This 
failure  of  the  tables  to  agree  with  the  other 
signs  of  malnutrition  is  explained  by  the  fact 

*  See  revised  table  in  Appendix  I,  p.  305. 
13 


NUTRITION  AND  GROWTH  IN  CHILDREN 

that  their  averages  are  made  up  of  measure- 
ments, not  only  of  children  who  have  attained 
normal  growth,  but  also  of  those  who  for  vari- 
ous reasons  have  been  retarded.  These  tables 
are  thus  vitiated  as  normal  standards,  although 
recognized  as  valuable  statistics  of  average  de- 
velopment. It  may  be  urged  that  the  under- 
weight children  are  balanced  by  those  who  are 
overweight,  but  the  examination  of  large  groups 
shows  that  the  percentage  of  overweight  is  rel- 
atively small,  and  is  more  than  compensated  by 
the  borderline  cases,  while  the  seriously  under- 
weight group  comprises  from  one-fourth  to  one- 
third  of  the  total. 

The  Malnourished. — After  accepting  a  table 
of  averages,  however,  it  was  still  necessary  to 
determine  what  range  of  variation  is  compatible 
with  conditions  of  reasonably  good  health  and 
growth.  Ten  per  cent  underweight  was  first 
taken  as  the  limit  best  corresponding  to  the 
other  clinical  evidence  of  malnutrition,  but  it 
soon  became  evident  that  many  children  in  need 
of  care  would  escape  under  this  rule.  Observa- 
tion of  a  large  number  of  children  indicated 
seven  per  cent  as  a  more  reliable  minimum,  and 
this  is  the  measure  now  used  in  our  nutrition 
classes.  In  the  application  of  this  rule  I  have 
never  seen  a  child  hahitually  seven  per  cent  un- 

14 


IDENTIFYING  THE  MALNOURISHED  CHILD 

derweight  for  his  height  who  did  not  show  other 
marked  signs  of  malnutrition. 

Stress  is  laid  upon  the  word  "habitual"  in 
this  consideration  of  underweight,  because, 
while  there  is  often  loss  of  weight  that  is  the 
result  of  temporary  conditions,  in  the  greater 
number  of  instances  underweight  has  continued 
during  the  major  part  of  the  growing  period, 
causing  the  child  to  be  not  only  under  weight 
but  under  height  also.  In  other  words,  the  child 
is  stunted,  and  tends  to  remain  so  unless  ade- 
quate measures  are  taken  to  remedy  his  condi- 
tion. 

Studies  made  in  Europe  indicate  that  boys 
placed  at  an  early  age  in  military  institutes, 
where  they  had  special  care,  on  reaching  ma- 
turity attained  greater  height  and  weight  than 
other  male  members  of  the  same  families.  Men- 
del likewise  reports  that  "in  the  recent  war 
large  groups  of  soldiers  from  certain  quarters 
of  London,  after  a  short  term  under  the  more 
healthful  conditions  of  military  service,  became 
so  much  taller  and  heavier  that  they  required 
entirely  new  outfits." 

A  small  percentage  of  children  show  an  ap- 
parently normal  relation  between  weight  and 
height,  but  nevertheless  fall  below  the  average 
in  both  respects.    These  children  are  also  defi- 

15 


NUTRITION  AND  GROWTH  IN  CHILDREN 

nitely  stunted.  ¥nder  proper  health  conditions, 
however,  a  capacity  for  growth  in  both  weight 
and  height  is  shown  in  many  cases.  This  group 
includes  those  constitutionally  affected  by  such 
conditions  as  syphilis,  deficient  thyroid,  the  ef- 
fect of  drugs,  and  children  who  are  recovering 
from  long  continued  illness. 

It  is  a  common  error  to  take  it  for  granted 
that  a  child  will  never  attain  average  size  be- 
cause he  is  supposed  to  "take  after"  some  un- 
dersized uncle  or  grandfather.  It  is  easy  to 
fall  back  upon  heredity,  and  say,  *'He  will  never 
be  a  large  man  for  he  is  just  like  my  father." 
While  a  child  may  inherit  certain  traits  from 
one  ancestor,  he  may,  in  other  respects,  resem- 
ble another  of  very  different  characteristics. 
Furthermore,  it  is  unfair  to  a  child  to  set  limits 
to  his  physical  development  until  he  has  been 
given  every  possible  chance  to  reach  the  best 
growth  that  is  in  him.  He  should  be  expected  to 
come  up  to  normal  until  every  cause  that  might 
check  his  growth  has  been  removed. 

The  application  of  the  seven  per  cent  rule  to 
any  group  of  children  will  identify  from  80  to 
90  per  cent  of  those  in  urgent  need  of  nutri- 
tional care. 

Borderline  Cases. — There  will  also  be  found 
a  considerable  number  of  ''borderline"  cases 

16 


Figure  3.     now  to  measure 


This  shows  the  correct  position  for  mcasiirini:  heiiiht.  The  child  stands 
with  IVet  together,  with  heels.  Imck.  and  head  toiuhinij  the  wall.  A 
book  or  block  resting  on  tlic  top  of  the  head  and  licid  against  the  wall 
Is  more  accurate  than  a  ruler  or  flexible  rod  which  is  apt  to  slip 
down  at  the  back.  A  tape  measure  attached  to  the 
wall  indicates  the  number  of  inches. 


IDENTIFYING  THE  MALNOURISHED  CHILD 

who  are  less  than  seven  per  cent  underweight, 
and  who  may,  if  neglected,  easily  fall  further 
below  their  normal  standard.  These  children 
should  be  brought  up  to  proper  condition  as 
well,  for,  while  they  may  not  be  strictly  called 
malnourished,  they  are  proportionately  less 
able  to  endure  special  strain  or  sudden  illness. 

Ideal  Weight. — It  must  be  recognized  that 
any  table  made  up  of  averages  is  only  an  ap- 
proximate standard,  and  every  child  has  his 
own  individual  normal  standard  which  he  will 
reach  under  sufficiently  favorable  conditions. 
Many  children  in  our  nutrition  classes  who 
reach  the  average  weight  for  their  height,  and 
are  therefore  ready  to  ** graduate,"  will,  if  kept 
in  the  classes  for  a  longer  period,  run  up  to  10 
per  cent  above  this  average  and  then  remain 
practically  stationary,  gaining  in  weight  only 
in  proportion  to  their  growth  in  height.  This 
would  indicate  that  the  best  development  is 
reached  when  a  child's  weight  is  about  10  per 
cent  above  the  average  indicated  in  these  tables. 

During  the  growing  period  size  does  count. 
Although  it  may  happen  that  a  child  who  is 
small  for  his  age  shows  remarkable  progress  in 
other  respects,  nevertheless  any  investigation 
of  a  large  number  of  children  will  demonstrate 
that  those  who  are  taller  and  heavier  as  a  rule 

17 


NUTRITION  AND  GROWTH  IN  CHILDREN 


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FlGUEE  4.     A  GAIN  OP  31  POUNDS  IN  21   WEEKS 

Clayton  C,  aged  eleven  years,  was  29  per  cent  underweight  for  his 
height.  He  was  "tall  for  his  age,"  59.2  inches,  which  is  the 
average  height  for  a  boy  of  fourtepn.  It  was  thought  that  he 
"could  not  grow  both  ways  at  once,"  but  his  chart  shows  a  steady 
climb  to  the  average  weight  line,  which  he 
reached  in  21  weeks. 


have  the  advantage  both  in  health  and  in  men- 
tal development. 

18 


IDENTIFYING  THE  MALNOURISHED  CHILD 

The  Overweight. — Clinical  experience  indi- 
cates that  when  a  child  is  20  per  cent  above  the 
average  weight  for  his  height,  he  has  reached 
a  point  where  his  weight  should  receive  atten- 
tion, and  he  will  be  better  off  if  he  does  not  ex- 
ceed this  percentage.  Children  whose  weight 
goes  beyond  this  point  begin  to  show  lessened 
activity  and  a  general  lowering  of  health,  con- 
venience, and  comfort.  They  are  to  be  consid- 
ered obese  and  in  need  of  care.  This  percentage 
corresponds  with  the  limit  set  by  insurance  com- 
panies in  regard  to  adults. 

How  to  Weigh  and  Measure. — There  should 
be  scales  in  every  home.  It  is  important  that 
the  same  scales  be  used  for  each  weighing,  be- 
cause scales  vary  and  false  records  may  other- 
wise be  made.  The  child  should  also  be  weighed 
at  the  same  hour  each  time,  as  there  may  be  a 
variation  of  one  or  two  pounds  according  to  the 
time  of  day.  Weight  should  be  taken  with  in- 
door clothing  but  without  shoes. 

In  measuring  height  it  is  necessary  to  make 
sure  that  the  measuring  rod  is  at  a  right  angle 
and  held  rigidly  in  place.  A  slight  slip  in  posi- 
tion may  make  a  difference  of  half  an  inch  in 
the  result,  which  means  one  to  three  pounds  in 
the  required  weight. 

19 


NUTRITION  AND  GROWTH  IN  CHILDREN 

The  use  of  a  weight  chart,-  such  as  we  have 
adopted  for  nutrition  classes,  will  help  to  visual- 
ise the  child's  condition,  and  encourage  his  ef- 
forts to  gain.  The  chart  should  have  a  line 
showing  the  average  weight  to  be  attained,  and 
an  actual  weight  line  made  from  the  weekly 
weighings.  When  the  child's  weight  reaches 
the  average  line  drawn  at  the  time  of  the  first 
weighing,  his  height  should  be  measured  again 
in  order  to  allow  for  the  normal  rate  of  growth 
during  the  interval.  The  average  weight  for 
this  new  height  is  his  present  normal  weight, 
and  is  the  standard  used  for  *' graduation'* 
from  our  nutrition  classes. 

Parents  too  often  consider  the  height  of  a 
child  by  itself,  and  assume  that  he  is  growing 
properly  because  he  is  taller  than  the  average. 
They  even  boast  that,  "At  ten  he  is  already 
wearing  a  twelve-year  suit!"  The  important 
point,  however,  is  neither  his  height  nor  his 
weight  at  any  particular  age,  but  whether  he  has 
a  body  of  sufficient  weight  to  sustain  his  height, 
whatever  his  age  or  his  height  may  be.  As  the 
child  grows,  every  advance  in  inches  calls  for 
a  corresponding  advance  in  pounds. 

2  See  Form  VIII  in  Appendix  II,  p.  318. 
20 


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p  o  a 


CHAPTER  III 

THE   CASE   HISTORY 

After  identifying  the  malnourished  child  by 
means  of  weighing  and  measuring,  further  in- 
vestigation is  then  required  to  determine  the 
cause  of  his  malnutrition.  This  must  always 
be  an  individual  study,  and  successful  treat- 
ment cannot  be  inaugurated  without  a  diagnosis 
as  accurate  as  that  which  determines  pneumo- 
nia, malaria,  or  other  diseases.  In  order  to  find 
the  cause  of  the  child's  condition,  a  history  and 
examination  form  ^  has  been  adopted  that  pro- 
vides for  thorough  physical-growth,  mental,  and 
social  examinations  as  well  as  for  the  child's 
history  in  detail. 

It  is  of  fundamental  importance  that  both  par- 
ents be  present  for  this  history  taking  and  dur- 
ing the  physical  examination.  They  are  both 
parties  to  the  business  of  getting  the  child  well, 
and  it  is  only  fair  to  him  that  they  understand 
the  significance  of  his  history  and  of  every 
defect  discovered.    The  father  and  mother  must 

^  See  Form  IX  in  Appendix  II,  facing  p.  320. 
21 


NUTRITION  AND  GROWTH  IN  CHILDREN 

be  depended  upon  faithfully  to  carry  out  all 
directions  given,  and  therefore  they  must  be 
made  to  see  clearly  what  is  necessary  to  bring 
about  recovery. 

It  may  seem  to  them  quite  unnecessary  to  set 
forth  all  the  details  listed  because  they  feel  sure 
they  remember  everything  that  has  happened  to 
the  child  since  his  birth.  Yet  these  facts,  writ- 
ten down  in  order,  present  a  significance  that 
may  easily  escape  the  observer  who  considers 
them  one  at  a  time  and  unrelated.  A  careful 
and  complete  history  is  of  the  greatest  help  to 
the  physician  in  making  his  diagnosis. 

The  Family  History. — The  first  group  of 
questions  in  the  form  relates  not  to  the  child 
himself,  but  to  his  parents,  brothers,  and  sis- 
ters. The  answers  to  these  questions  give  the 
physician  important  information  as  to  the  fac- 
tor of  heredity  and  the  existence  in  the  family 
of  certain  diseases  that  may  be  revealed  by  the 
causes  of  death.  For  example,  syphilis  is  sug- 
gested by  the  report  of  miscarriages  or  of  still 
births. 

Birth  and  Infancy. — The  second  section  has 
to  do  with  the  capital  with  which  the  child  began 
life  and  facts  as  to  his  early  development.  His 
condition  at  birth  is  significant.  DiflQcult  labor 
may  have  caused  mental  defect,  which  may  be 

22 


CASE  HISTORY 

indicated  by  slow  progress  in  walking  or  talk- 
ing. Knowledge  of  the  child's  early  care  not 
Dnly  further  indicates  his  start  in  life,  but  also 
the  intelligence  of  his  parents. 

Previous  Diseases. — The  next  division  takes 
account  of  the  more  serious  illnesses  which  the 
child  has  had.  By  the  dates  of  their  occurrence 
various  complications  may  be  traced.  Attacks 
of  earache  should  be  noted,  and  record  made  of 
any  bad  effects  that  followed  measles,  tonsil- 
litis, whooping  cough,  scarlet  fever,  or  any 
other  acute  infectious  disease.  The  dates  of 
previous  operations  should  be  given. 

General  Health  and  Habits. — The  food  and 
health  habits  of  the  child  are  the  basis  of  the 
next  group  of  questions,  and  this  section  is  of 
more  importance  than  is  commonly  realized, 
because  faulty  habits  in  many  small  matters  of 
diet  and  health  are  a  common  cause  of  malnu- 
trition. If  several  members  of  the  family  are 
malnourished,  there  is  probably  a  common 
cause  such  as  the  use  of  tea  and  coffee,  improper 
diet,  or  poor  hygiene.  Exact  information  is 
desirable  on  all  these  points.  The  physician 
will  want  to  know,  for  example,  not  only 
whether  the  child  eats  candy,  but  "How  much 
candy  does  he  eat?" 

The  mother  should  think  back  over  the  child's 
23 


NUTRITION  AND  GROWTH  IN  CHILDREN 

condition  at  various  ages,  and  record  the  time 
when  he  may  have  been  well  and  strong,  as  well 
as  the  circumstances  that  attended  the  begin- 
ning of  his  less  favorable  condition. 

Present  Symptoms. — The  physician  will  also 
question  the  parents  as  to  their  own  diagnosis 
of  the  child's  condition  by  such  questions  as, 
**Just  what  is  the  chief  complaint  I"  '^What 
led  you  to  bring  him  to  me?"  They  may  have 
a  very  erroneous  idea  of  what  is  the  matter  with 
the  child,  but  it  is  nevertheless  desirable  to  hear 
their  story.  In  this  way  much  useful  informa- 
tion may  be  secured,  as  well  as  an  understand- 
ing of  the  situation  with  regard  to  home  con- 
trol and  discipline.  Unconscious  remarks  by 
the  parents  will  often  throw  light  on  the  real 
cause  of  the  child's  malnutrition. 

Wliile  no  history  form  can  cover  all  the  points 
that  may  be  necessary  to  discover  the  cause  of 
the  malnutrition,  yet  this  outline  should  be 
carefully  completed  for  each  child,  and  further 
points  added  as  may  seem  to  be  important. 

Impressions  received  through  the  history- 
taking  will  direct  special  attention  to  certain 
points  of  the  physical,  mental,  and  social  exam- 
inations that  are  to  follow,  and  in  this  way  lead 
to  a  more  accurate  diagnosis. 


CHAPTER  IV 

THE  PHYSICAL-GEOWTH  EXAMINATION 

The  physical-growth  examination  is  of  great 
importance  to  the  physician,  not  only  for  pur- 
poses of  diagnosis  and  treatment,  but  also  as 
an  opportunity  to  demonstrate  to  the  parents 
the  true  condition  of  the  child.  This  examina- 
tion as  given  in  our  nutrition  classes  differs 
from  the  usual  type  not  only  in  the  complete- 
ness of  the  medical  part  of  the  investigation, 
but  in  taking  account  of  defects  affecting  growth 
which  are  commonly  overlooked.  That  these 
defects  are  significant  is  demonstrated  by  the 
fact  that  underweight  children  have  an  average 
of  nearly  six  defects,  while  in  children  more 
than  20  per  cent  overweight  the  average  is  less 
than  two. 

The  examining  room  should  be  quiet,  and 
have  adequate  light  and  heat.  Besides  the 
usual  instruments,  there  should  be  an  electric 
otoscope,  scales  for  taking  weight,  and  a  meas- 
uring rod  for  determining  height.  The  child's 
clothing  should  be  removed  so  that  his  general 
condition  may  be  observed  and  all  defects  of 

25 


NUTRITION  AND  GROWTH  IN  CHILDREN 


growth  and  posture  noted.  A  man  who  judges 
animals  knows  how  much  would  be  hidden  if  a 
horse,  for  example,  were  inspected  when  cov- 
ered by  a  blanket.    Yet  this  amounts  to  the  same 


Weighing 


Measuring 


Mal-nouristied  child 


Complete  examination 


Mental  examination    Physical  growth  pxammatipn    Social  examination 


[OiyDsiticm  tenjeftn   Mkw\^ 


Medical    Surgical 


48H0uf 
proErarr 


Completp  diasnosis  of  causes  ofmalnutntion 


Treatmenr 


Medial  cars 

Dier 

H/giene 


Prevenrion 
of  fatigue 


Mental 
care 


Figure  6.    cojiplete  examination 

Diagnosis   must  be   based   on   a    complete   physical-growth,    mental, 
and   social   examination." 

thing    as    the    examination    of    a   child   when 
dressed. 

The  results  of  a  thorough  physical  examina- 
tion made  in  this  manner  are  usually  a  revela- 
tion to  the  parents.  A  child  with  a  round,  at- 
tractive face  passes  as  well  nourished  when  an 
examination  without  clothing,  or  even  in  under- 
clothing would  disclose  serious  physical  defects. 

26 


PHYSICAL-GROWTH  EXAMINATION 

Such  au  inspection  by  parents  in  the  home 
would  often  lead  to  earlier  discovery  of  a  seri- 
ous condition. 

The  objection  is  sometimes  raised  that  the 
complete  physical-growth  examination  takes 
more  time  than  can  be  spared  for  it.  But  the 
thoroughness  of  the  examination  does  away 
with  the  necessity  for  its  repetition,  and  knowl- 
edge of  the  true  condition  of  the  child  at  the 
outset  saves  both  time  and  misdirected  effort. 
In  one  of  our  nutrition  classes  a  boy  who  had 
been  examined  in  the  usual  way  and  reported  to 
be  in  normal  condition  was  found  to  need  care 
for  the  following  defects : 

1.  Fifteen  per  cent  underweight  for  height 

2.  Mouth  breathing 

3.  Adenoids 

4.  Hypertrophic  pharyngitis 

5.  Diseased  tonsils 

6.  Enlarged  cervical  glands 

7.  Five  carious  teeth 

8.  Cerumen  in  both  ears 

9.  Round  shoulders 
10.  Adherent  prepuce 

This   is  one  of  the  worst  cases  encountered, 
yet  five  per  cent  of  the  group  to  which  he  be- 
longed had  10  or  more  defects  each. 
A  defect  may  be  either  the  cause  or  the  effect 
27 


NUTRITION  AND  GROWTH  IN  CHILDREN 

of  malnutrition.  Those  that  consist  of  inflam- 
matory processes  are  usually  causes,  while  pos- 
tural defects  are  usually  results. 

Physical  Signs. — The  expression  of  the  face 
and  eyes  is  an  important  sign  of  malnutrition. 
The  serious,  drawn  look  with  lines  under  the 
eyes  is  significant.  There  is  usually  pallor,  a 
lack  of  the  glow  of  health,  and  the  hair  seems 
**dead."  The  skin  loses  its  normal,  pink  color, 
becomes  rough,  and  is  sometimes  so  loose  that 
it  can  be  '' picked  up"  and  separated  from  the 
subcutaneous  tissues.  The  lips  of  the  mouth 
breather  are  dry  and  crusted. 

The  malnourished  child's  muscles  are  flabby. 
This  is  most  easily  tested  by  feeling  the  muscles 
of  the  upper  arm.  Similar  weakness  is  shown 
by  the  very  common  "fatigue  posture,"  evi- 
denced both  in  sitting  and  standing.  By  this 
we  mean  the  position  with  the  head  set  forward, 
v-ound  shoulders  with  protruding  shoulder 
blades,  flat  chest,  prominent  abdomen,  and  pro- 
nated  or  flat  feet.  This  "fatigue  posture"  is 
one  of  the  most  serious  results  of  malnutrition. 
The  prominent  abdomen,  due  to  relaxed  walls, 
may  not  be  evident  when  the  child  is  lying  flat, 
"but  is  well  marked  in  a  standing  position.  The 
visceroptosis  causes  digestive  disturbance  and 
lowered  vitality. 

28 


Figure  7.    a  typical  malnourished  child 

Alfred  H.,  aged  nine  years.  Notice  his  serious  expression,  mouth 
breathing,  lines  under  the  eyes,  thin  arms  and  legs,  and  pronated  feet. 
Alfred  was  under  observation  over  three  years  before  his  (.ase  was 
fimllv  dia>'no^ed  as  congenital  duodenal  obstruction.  His  detects  were: 
underwei<'bt  17  per  cfut  i'.t  Ib.i  ;  naso-pliaryngt-al  obstruction;  carious 
teeth  (eight)  ;  fatigue  posture:  habit  spasm;  congenital  duo- 
denal obsliuction  (bands;   with  gastric  dilatation. 


PHYSICAL-GROWTH  EXAMINATION 

Naso-Pharyngeal  Obstruction. — Obstruction 
in  the  nose  and  pharynx  is  perhaps  the  most 
important  of  all  defects  in  its  relation  to  nutri- 
tion, and  its  most  common  symptom  is  mouth 
breathing.  As  the  child  may  keep  his  mouth 
closed  while  receiving  the  attention  of  the  ex- 
aminer, this  sign  may  pass  unnoticed,  but  he 
should  be  watched  when  he  is  not  aware  of  ob- 
servation, and  if  the  lips  are  parted,  the  throat 
specialist  should  be  consulted. 

Controlled  observation  in  the  nutrition  class, 
with  the  weight  chart's  record  of  gain  or  loss, 
is  one  of  the  most  valuable  means  of  diagnosing 
focal  infections.  The  failure  to  gain  when 
other  causes  have  been  eliminated  should  lead 
to  further  examination  of  the  naso-pharynx,  and 
in  doubtful  cases  this  may  reveal  decisive  evi- 
dence of  a  needed  operation. 

Enlarged  anterior  cervical  glands  indicate 
diseased  tonsillar  tissue  and  a  consequent  ab- 
sorption of  toxins.  Dull  ear  drums  also  sug- 
gest a  sub-acute  inflammatory  process  extend- 
ing from  the  throat. 

Even  where  children  have  had  several  ade- 
noid and  tonsil  operations,  there  may  be  dis- 
eased tissue  remaining  that  is  walled  in  by 
cicatrices,  thus  preventing  drainage.  The 
child's  health  may  be  worse  as  a  result  of  this 

29 


NUTRITION  AND  GROWTH  IN  CHILDREN 

condition  than  it  was  before  the  operation. 
Such  infected  tissue  must  be  removed  before  the 
child  is  ' '  free  to  gain. ' ' 

In  Figure  8  is  shown  a  composite  graph  of  15 
cases  which  required  more  than  one  operation 


Figure  8.    effect  of  adenoid  and  tonsil  opebations 

This  chart  shows  the  average  sain  of  a  group  of  15  children  after 
adenoid  and  tonsil  operations,  as  compared  with  their  gain  before 
tlie  operations — in  tlic  one  case,  ITVij  ounces  a  week,  in  the  other,  3 
ounces,  with  practically  the  same  amount  of  food.  Their  failure  to 
gain  while  under  observation  in  the  nutrition  class  was 
the  determining  factor  in  diagnosis. 

before  the  children  could  be  made  to  gain  satis- 
factorily. Their  delay  in  growth  was  rightly 
interpreted  as  additional  evidence  of  the  pres- 
ence of  diseased  tissue  in  the  throat  causing 

30 


PHYSICAL-GROWTH  EXAMINATION 

toxins  to  enter  the  body.  It  should  be  remem- 
bered that  the  effect  of  focal  infection  is  more 
marked  on  the  general  system  than  on  local  tis- 
sues, so  that  poor  physical  condition  may  be 
stronger  evidence  of  toxic  effect  than  the  ap- 
pearance of  the  throat  itself. 

Sinus  infection  is  more  common  than  is  gen- 
erally supposed.  The  sinuses  in  children  are 
small,  but  infection  may  occur  secondary  both 
to  naso-pharyngeal  obstruction  and  to  decayed 
teeth. 

Teeth  Defects. — It  is  generally  assumed  that 
carious  teeth  cause  malnutrition.  A  careful 
study  made  of  several  hundred  children,  how- 
ever, fails  to  establish  this  relationship.  In 
fact  there  seems  to  be  no  evidence  available 
that  small  cavities  in  the  teeth  directly  affect 
nutrition  unless  there  are  also  abscesses  or 
other  inflammatory  conditions  present. 

In  the  group  studied  ^  it  was  found  that  those 
who  had  carious  teeth  showed  7  to  22  per 
cent  greater  incidence  of  postural  defects  and 
4  to  16  per  cent  more  obstructions  to  breath- 
ing than  those  who  were  free  from  teeth  de- 
fects, but  no  such  apparent  relation  to  under- 

1  "Physical  Defects  in  Children."  Report  of  602  cases. 
(Pamphlet  No.  8  in  List  of  Publications,  p.  332.) 

31 


NUTRITION  AND  GROWTH  IN  CHILDREN 

weight  was  indicated.  Even  when  the  com- 
parison was  made  between  the  children  having 
many  and  those  having  few  defects  of  each  kind, 
the  proportion  of  underweight  increased  with 
the  number  of  naso-pharyngeal  defects  but  not 
with  defects  of  the  teeth. 

In  another  study,^  88  children  Were  divided 
into  four  nearly  equal  groups — the  first  having 
no  carious  teeth;  the  second,  one  each;  the 
third,  two  and  three;  and  the  fourth,  four  to 
twelve.  The  percentages  of  malnutrition  ran 
10,  9,  10,  and  10,  respectively,  showing  no  sign 
of  correlation. 

There  are  excellent  reasons  for  insisting 
upon  the  care  of  the  teeth,  but  the  studies  that 
have  been  made  do  not  justify  the  assumption 
that  small  cavities  are  a  direct  cause  of  malnu- 
trition. 

Medical  Defects. — In  extreme  cases  of  mal- 
nutrition hereditary  syphilis  should  always  be 
suspected  as  a  cause.  Therefore  the  Wasser- 
mann  test  should  be  made  as  a  routine  matter, 
especially  in  institutional  cases.  X-ray  exam- 
ination of  the  long  bones  is  an  aid  in  this  diag- 
nosis. 


2  "A  Nutrition  Clinic  in  a  Public  School."     (Pamphlet 
No.  1  in  List  of  Publications,  p.  332.) 

32 


PHYSICAL-GROWTH  EXAMINATION 

Vaginitis  of  gonorrheal  origin  will  also  be 
found  among  cases  admitted  to  institutions  and 
out-patient  departments. 

Pyelitis  is  not  uncommon,  especially  in  girls. 
The  detection  of  this  condition  often  requires 
more  than  one  urine  examination  because  of  its 
remissions  and  exacerbations. 

An  X-ray  examination  of  the  chest  may  dis- 
cover obscure  tubercular  lesions,  and  the  von 
Pirquet  test  should  be  employed  to  rule  out 
tuberculosis. 

Temperature  charts  are  useful  in  determining 
obscure  infections.  Malnourished  children  fre- 
quently run  a  slight  evening  temperature,  and 
in  these  cases  observation  in  bed  with  a  4-hourly 
chart  may  be  helpful.  A  sub-normal  tempera- 
ture is  a  sign  of  low  vitality,  and  may  indicate 
the  need  for  rest  in  bed. 

Intestinal  parasites  and  their  eggs  should  be 
looked  for  by  an  examination  of  the  feces  under 
the  microscope.  Eosinophilia  may  be  another 
indication  of  worms. 

An  X-ray  examination  of  the  alimentary  tract 
will  assist  in  the  diagnosis  of  cardiospasm, 
pyloric  stenosis,  intestinal  adhesions,  or  chronic 
appendicitis. 

Examination  of  the  blood  of  malnourished 
children   does   not   usually   show   anemia,   al- 

33 


NUTRITION  AND  GROWTH  IN  CHILDREN 

though  this  condition  may  obtain  as  a  result  of 
the  tea,  coffee,  or  candy  habit. 

Where  there  is  an  eczema  or  skin  eruption, 
accompanied  by  bronchitis  or  asthma,  a  condi- 
tion of  anaphylaxis  is  to  be  suspected,  and  the 
cutaneous  proteid  tests  should  be  made.  This 
is  a  not  infrequent  cause  of  malnutrition,  and 
these  tests  are  the  best  helps  we  have  in  arrang- 
ing a  diet  on  which  the  child  will  gain.  Im- 
paired ability  to  digest  and  assimilate  food 
under  this  condition  calls  for  longer  rest  pe- 
riods and  special  guarding  against  over- 
fatigue. 

Defects  at  Various  Ages. — In  a  recent  study 
of  602  children,  ranging  in  age  from  2  to  15 
years,  we  found  an  average  of  six  defects  per 
child.  No  evidence  was  shown  of  any  particular 
period  in  which  there  is  a  greater  tendency  to 
defect,  as  there  was  remarkable  uniformity  in 
the  number  of  defects  at  all  the  ages  included. 

The  significance  of  various  defects  may  vary, 
however,  with  the  age  of  the  child.  Because  of 
the  small  size  of  the  naso-pharynx,  for  example, 
an  excess  of  adenoid  tissue  may  be  a  serious 
danger  during  infancy  and  the  pre-school  age, 
while  tonsils  do  not  as  a  rule  become  infected 
before  the  age  of  five  or  six.  Failure  to  gain  in 
weight  is  often  one  of  the  earliest  and  most  re- 

34 


FlOrRE  ^.      PEFORMITY  AM)  MALNTTRITIOX 


The  trno   oonrtition    of  tliosc   two  school    irirls  wns   brousrlit   out  bv   tho 

phvsiral-srrowth    oynniination    in    n    niifiition    rlnss    rondiiotpil    hv    the 

Elizabeth   MrCormick   Momorial    Fiinii   in    ('hi<-ai.'o.     Tho   usual   medical 

inspet'tinn   in  schools  docs  not  discover  such  basic 

defects  of  growth. 


PHYSICAL-GROWTH  EXAMINATION 

liable  signs  of  absorption  from  infected  tissue, 
and  the  early  removal  of  diseased  adenoids  and 
tonsils  is  important  in  preventing  pyelitis  and 
endocarditis  as  well  as  other  serious  complica- 
tions of  the  acute  infectious  diseases. 

The  Examination  Form. — All  the  defects 
most  commonly  found  are  printed  on  the  exam- 
ination form  used  in  our  nutrition  classes,  and 
these  are  simply  underlined  as  the  examiner 
proceeds.  The  completeness  of  the  form  enables 
the  parent  or  nutrition  worker  to  check  up  the 
record  and  see  that  no  detail  is  omitted.  The 
advantages  of  this  method  of  examination  both 
in  private  practice  and  hospital  work,  may  be 
summarized  as  follows : 

1.  Records  become  valuable  because  they  are 
standardized,  and  there  are  no  omissions. 

2.  Uniform  and  approved  nomenclature  is  used. 

3.  Dictation  can  be  taken  by  any  one  who  can 
read  and  write  as  well  as  by  a  stenographer, 
and  at  the  conclusion  of  the  examination  the 
complete  record  is  ready  for  inspection  without 
having  to  be  transcribed. 

4.  This  method  makes  it  easier  to  equalize  at- 
tendance at  a  clinic.  New  patients  appreciate 
the  completeness  of  the  physical-growth  ex- 
amination, and  are  willing  to  come  again  by 
appointment  in  case  the  day  happens  to  be 
unusually  busy. 

35 


NUTRITION  AND  GROWTH  IN  CHILDREN 

5.  It  aids  the  work  of  the  less  experienced  physi- 
cian by  listing  completely  the  points  to  be  ob- 
served. In  general  it  may  be  said  that  mis- 
takes are  made  not  from  lack  of  knowledge  on 
the  part  of  the  doctor,  but  because  he  has 
failed  to  look. 

6.  It  insures  greater  thoroughness.  From  100  to 
200  per  cent  more  abnormalities  are  found  by 
this  method  than  by  the  usual  examination, 
even  when  made  by  specialists  in  the  best 
clinics. 

7.  It  saves  unnecessary  repetition  of  examina- 
tions. Under  the  usual  hospital  procedure  if 
a  child  returns  to  the  clinic,  he  frequently  has 
to  be  undressed  and  reexamined  because  previ- 
ous records  are  incomplete. 

8.  Such  basic  examinations  are  accepted  when  a 
patient  is  referred  to  another  department,  be- 
cause the  name  of  the  examiner  is  on  the  form, 
and  he  can  be  held  accountable  for  what  he 
has  signed. 

9.  It  adds  interest  to  the  work  of  the  examiner, 
and  enables  him  to  receive  credit  for  good 
work.  It  also  increases  work  in  preventive 
medicine  because  defects  are  almost  invariably 
found  other  than  those  which  brought  the  pa- 
tient to  be  examined. 

10.  It  assists  the  administrative  and  medical  social 
service  departments  of  the  hospital  by  defi- 
nitely recording  all  abnormalities  that  need 
correction. 

36 


PHYSICAL-GROWTH  EXAMINATION 

The  following  case  admitted  to  one  of  our 
nutrition  clinics  illustrates  this  point: 

A  child-helping  institution  inquired  for  a 
diagnosis  of  the  condition  of  Charles  S.  The 
nutrition  worker  found  his  record,  and  was  able 
to  answer  immediately: 

"Charles  S.  was  examined  here  December  27.  His 
general  condition  was  found  to  be  poor.  He  was  12 
per  cent  underweight  for  his  height,  had  round  should- 
ers, pediculosis,  and  two  carious  teeth.  He  had  naso- 
pharyngeal obstruction,  and  was  apparently  retarded 
mentally.  Treatment  has  been  prescribed  for  pedicu- 
losis and  an  appointment  made  to  have  him  examined 
in  the  throat  department.  He  is  to  report  here  in  a 
week,  bringing  a  list  of  food  taken  during  48  con- 
secutive hours  in  order  that  his  food  habits  may  be 
determined.  The  examiner  suggested  that  he  be 
tested  mentally,  and  that  inquiry  be  made  as  to  his 
work  in  school.  After  he  gains  in  weight  he  should 
have  corrective  exercises." 

The  inquirer  replied :  / 

"That  is  just  what  we  wanted  to  know," 

and  added: 

"We  will  have  the  dentist  attend  t^^^  *^^^^'  and 
see  that  the  directions  for  pediculos'^^®  carried  out. 

37 


NUTRITION  AND  GROWTH  IN  CHILDREN 


GQ 

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38 


wo       *   6C  O 
'■  d)  ^       t-   ^  4» 


PHYSICAL-GROWTH  EXAMINATION 

We  had  suspected  a  condition  of  diseased  tonsils  and 
adenoids,  and  shall  be  interested  to  receive  a  further 
report  on  that  matter.  We  are  glad  to  cooperate  with 
you  in  regard  to  his  food  habits,  and  will  arrange 
immediately  for  a  special  mental  examination." 

At  the  end  of  six  months  Charles  S.  had 
gained  normal  weight,  and  was  in  excellent 
physical  condition.  His  adenoids  and  tonsils 
had  been  removed,  and  all  the  treatment  recom- 
mended in  the  physical  examination  had  been 
carried  out.  He  was  found  to  be  mentally  re- 
tarded, and  special  classwork  was  provided  in 
school.  This  was  a  direct  saving  of  the  teach- 
er's energy,  for  she  had  been  giving  him  extra 
time  after  school  in  an  effort  to  "keep  him  up 
with  his  class." 

Contrast  this  report,  and  the  constructive 
work  accomplished  in  this  typical  case,  with  the 
reply  that  had  been  given  in  regard  to  the 
same  boy  following  an  examination  made  two 
weeks  before  he  was  admitted  to  the  nutrition 
clinic: 

*'Yes,  Charles  S.  was  examined,  but  evidently  the 
doctor  found  nothing  serious  the  matter  with  him,  as 
he  simply  gave  general  directions  about  his  hygiene, 
and  advised  that  if  he  was  not  all  right  he  should 
report  again  in  two  months. ' ' 

39 


NUTRITION  AND  GROWTH  IN  CHILDREN 

The  relative  results  of  the  two  methods  of 
examination  is  shown  in  the  foregoing  table  of 
defects  found  in  50  children  who  were  patients 
in  one  of  our  largest  and  best  organized  chil- 
dren's clinics,  as  compared  with  the  record  of 
the  same  children  examined  in  the  nutrition 
clinic  according  to  the  basic  method  here  de- 
scribed. The  table  shows  first,  the  defects  ap- 
pearing in  the  hospital  diagnosis  summary; 
second,  additional  defects  mentioned  in  the  gen- 
eral examination  but  not  appearing  in  the  sum- 
mary; third,  the  sum  of  these  two  columns,  or 
all  defects  recorded  as  a  result  of  the  general 
examination;  fourth,  the  defects  found  in  the 
examination  made  at  the  nutrition  clinic;  fifth 
and  sixth,  comparisons  in  the  form  of  percent- 
ages. 

It  will  be  seen  that  the  general  examination 
recorded  only  44  per  cent,  or  less  than  half  the 
defects  appearing  in  the  register  of  the  nutri- 
tion clinic.  When  the  number  of  defects  ap- 
pearing in  the  diagnosis  summary  is  compared 
with  the  nutrition  record,  the  disparity  is  even 
greater,  the  summary  recording  only  21  per 
cent,  or  less  than  one-quarter  of  the  actual  de- 
fects. In  the  naso-pharyngeal  group  the  sum- 
mary showed  only  9  per  cent  of  the  defects 
found,  and  the  nearest  approach  to  the  com- 

40 


Figure  10.    six  malnourished  girls 


This  is  a  srroiip  at  tlie  Massachusotts  ficnoial  Ilosiiital.  taken  as  they 
sat  in  tlio  nutrition  class  in  the  order  of  their  trains  for  a  neelc.  Their 
serious  expressions  are  characteristic,  quite  unlike  tliosc  of  liappy.  well 
cliildren  of  normal  weijrht.  Observe  the  round  shoulders,  thin  arms,  and 
protuberant  abdomens.  The  physical-growth  examination  con- 
vinced their  parents  of  the  need  of  'mmediate  care. 


PHYSICAL-GROWTH  EXAMINATION 

pleteness  of  the  nutrition  examination  was  47 
per  cent  in  the  case  of  teeth  defects. 

This  latter  comparison  with  the  diagnosis 
summary  is  a  fair  test  of  the  two  methods,  be- 
cause the  results  of  an  examination  are  almost 
sure  to  be  overlooked  if  they  are  not  brought 
down  to  the  summary,  from  which  the  recom- 
mendations are  usually  made.  It  may  be  urged 
that  the  general  examination  is  especially  con- 
cerned with  vital  organs,  and  consequently 
omits  less  serious  defects,  but  an  inspection  of 
the  details  of  the  more  complete  examination 
shows  no  defects  included  that  do  not  have 
direct  bearing  upon  the  child's  health. 

"Before  and  After"  Pictures. — Pictures  of 
the  child  taken  ^'before  and  after"  treatment 
(as  illustrated  on  pages  45, 184  and  186)  make  a 
valuable  supplement  to  the  physical  examina- 
tion. They  should  preferably  be  taken  without 
clothing,  but  where  this  is  not  practicable  any 
picture  of  the  child  will  prove  helpful.  The  ' '  be- 
fore" pictures  should  be  taken  at  the  time  of 
the  examination  and  not  deferred  until  the  child 
begins  to  show  improvement;  and  the  '* after" 
pictures  should  be  taken  in  the  same  relative 
position  in  order  to  show  the  contrast  after  the 
child  has  reached  his  normal  weight  line.    Care 

41 


NUTRITION  AND  GROWTH  IN  CHILDREN 

should  be  taken  to  make  these  photographs 
represent  true  conditions. 

In  large  clinics  a  single  picture  of  several 
children  in  line  can  be  taken.  This  picture  will 
serve  not  only  for  group  purposes  by  illustrat- 
ing the  prevalence  of  certain  conditions,  such  as 
fatigue  posture,  but  it  can  be  cut,  and  the  single 
picture  attached  to  the  record  will  serve  to 
identify  the  individual  child.    (See  Figure  10.) 


CHAPTER  V 

THE   MENTAL    EXAMINATION 

Malnutrition  does  not  cause  mental  defi- 
ciency, but  it  does  result,  at  times,  in  a  mental 
retardation  closely  resembling  the  actual  state 
of  defect.  Many  children  who  are  under  par 
physically  manifest  symptoms  that  are  inter- 
preted as  indications  of  deficiency,  when  they 
are  in  reality  signs  of  nervous  strain  and  over- 
fatigue, or  irritability  and  dullness  resulting 
from  toxemia  that  has  a  physical  and  remova- 
ble cause. 

Such  children  do  not  have  the  strength  to 
show  interest  in  their  studies,  and  falter  and 
fumble  at  their  tasks  in  a  way  that  is  exasper- 
ating to  those  in  charge  of  them.  Considered 
lazy,  they  are  told,  "Your  fingers  are  all 
thumbs,"  or  "  You  never  get  anything 
straight,"  or  "If  you  have  any  brains,  why  not 
use  them?"  But  such  expressions  merely  add 
to  the  child's  distress,  and  entirely  fail  to  im- 
prove his  condition,  the  real  cause  of  which 
must  be  determined. 

The  malnourished  child  is  frequently  back- 
43 


NUTRITION  AND  GROWTH  IN  CHILDREN 

ward,  forgetful,  unhappy,  over-sensitive,  and 
unreasonable  both  in  his  likes  and  his  dislikes. 
He  may  show  signs  of  irritability,  f retf nines s, 
peevishness,  inattention,  and  lack  of  concentra- 
tion and  yet  be  entirely  normal  in  his  mental 
development. 

Similarly,  such  physical  abnormalities  as 
hare-lip,  arched  palate,  ill-shapen  head,  ear,  or 
limb,  are  not  conclusive  proofs  of  mental  defi- 
ciency, although  they  are  more  frequently  found 
in  mentally  defective  than  in  normal  children. 
Individuals  vary,  but  any  wide  variation,  either 
mental  or  physical,  should  be  investigated. 

It  is  the  task  of  the  nutrition  clinic  to  de- 
termine by  careful  study  and  observation  the 
significance  of  any  of  these  symptoms  that  ap- 
I3ear  in  the  children  admitted  for  treatment. 
Mental  development  closely  parallels  physical 
development,  and  any  failure  on  the  part  of  a 
child  to  show  the  interests  and  activities  usual 
in  children  of  his  age  should  challenge  atten- 
tion. One  of  the  best  tests  is  the  first  impres- 
sion made  on  the  examining  physician.  If,  in 
addition  to  this,  the  history  shows  that  the  child 
did  not  walk  or  talk  at  two  years,  that  he  has 
been  difficult  to  get  along  with,  or  defiant  of 
fundamental  social  law,  this  combined  evidence 
justifies  a  thorough  mental  examination.     In 

44 


FiGtJBE  11.      MENTAL  RETARDATION  OR  MENTAL  DEFICIENCY 


Tom  was  11  per  cent  underwcisht.  a  mouth  hroather.  with  round 
shoulders,  tiat  chest,  spinal  curvature,  and  Hahb.v  muscles.  He  was 
oonsiden^d  stupid,  and  kept  after  school  in  a  vain  attempt  to  hold  him 
up  to  his  grade.  The  right  half  of  the  picture  shows  him  after  his 
diseased  adenoids  and  tonsils  had  been  removed  and  lie  had  followed 
directions  as  to  diet  and  rest.  The  transformation  in  his  con- 
dition can  be  seen  to  be  mental  as  well  as  physical. 


MENTAL  EXAMINATION 

most  communities  there  are  trained  experts  who 
can  pass  authoritatively  upon  a  child's  mental 
condition.  In  consulting  such  a  specialist  all 
available  data  from  the  nutrition  class  should  be 
supplied  him  to  aid  in  his  investigation  of  the 
child's  mental  health. 

In  questionable  cases,  however,  the  child 
should  be  given  the  benefit  of  the  doubt,  and  an 
effort  made  to  correct  his  malnutrition.  It 
should  be  remembered  that  the  unmanageable 
child  is  more  often  ill  than  bad  or  deficient. 
Any  marked  change  in  behavior  suggests  the 
onset  of  illness.  Fretfulness  from  rickets,  dull- 
ness and  lack  of  memory  from  adenoids,  irrita- 
ble peevishness  from  digestive  disorders,  and 
the  abnormal  mental  reactions  of  overfatigue 
all  yield  to  treatment  when  their  cause  is  once 
recognized,  and  a  mental  transformation  fre- 
quently takes  place  along  with  the  physical  im- 
provement. 

Even  where  the  child  is  found  mentally  de- 
fective, he  will  be  happier  and  his  mental  condi- 
tion will  improve  if  his  nutrition  is  brought  up 
to  normal.  The  condition  should  not  be  made 
an  excuse  for  neglect  or  lack  of  control,  which 
will  merely  aggravate  his  malady. 

Home  conditions  and  early  training  in  self- 
control  are  important  factors  in  leading  the 

45 


NUTRITION  AND  GROWTH  IN  CHILDREN 

child  to  normal  behavior.  1  have  seen  this  il- 
lustrated in  the  case  of  a  boy  who  was  so  utterly- 
defiant  of  parental  authority  that  he  would 
actually  fight  his  mother  with  feet  and  fists.  It 
was  thought  certain  the  child  was  mentally  de- 
ficient, but  before  accepting  this  explanation 
as  final,  it  was  decided  to  try  what  discipline 
and  a  change  of  environment  would  do.  He  was 
accordingly  sent  to  a  well  organized  boys' 
school,  and  at  the  end  of  the  year  the  master 
reported,  "He  is  a  little  gentleman." 

Life  for  many  undisciplined  children  is  an 
almost  unbroken  series  of  dissipations.  What 
they  want  they  must  have  at  any  sacrifice  of 
health,  or  even  of  character.  Such  children  be- 
come past  masters  in  the  art  of  getting  their 
own  way,  and  play  the  game  to  its  limit.  Many 
of  these  spoiled  boys  and  girls,  persisting  in 
the  attempt  to  have  their  own  way,  later  in  life 
overstep  the  moral  law  or  the  written  statute, 
and  bring  upon  themselves  disgrace  or  the  pen- 
alty exacted  by  the  state.  "While  their  conduct 
indicates  mental  impairment,  it  may  be  only  the 
logical  result  of  lack  of  training. 

The  mental  progress  of  children  from  three 
years  to  10  may  be  tested  according  to  the 
following  standards  from  the  Binet-Simon 
series : 

46 


MENTAL  EXAMINATION 

Three  years: 

Points  to  nose,  eyes,  and  moutli. 

Repeats  short  sentence. 

Picks  out  objects  in  picture. 
Four  years: 

Knows  sex. 

Recognizes  a  knife,  key,  etc. 

Repeats  three  numerals. 

Distinguishes  between  long  and  short  line. 
Five  years: 

Distinguishes  between  two  objects  of  different 
weight. 

Copies  a  square. 

Repeats  sentence  of  eight  or  ten  words. 

Counts  four. 
Six  YEARS: 

Knows  morning  and  afternoon 

Defines  simple  objects,  giving  the  use  as  a  defi- 
nition, for  instance,  a  fork  is  to  eat  with. 

Carries  out  simple  commands  involving  two 
or  three  things. 

Knows  right  and  left. 
Seven  years: 

Counts  thirteen  or  more. 

Describes  pictures. 

Copies  other  figures  than  squares. 

Knows  colors. 
Eight  years: 

Counts  backward  from  twenty  to  one. 

Gives  the  essential  difference  between  such  ob- 
jects as  glass  and  wood,  fly  and  butterfly. 

Knows  the  days  of  week. 

Repeats  five  numerals. 
47 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Nine  tears: 

Knows  the  date. 

Names  months  of  the  year. 

Makes  simple  change  in  handling  money. 

Gives  definition  of  objects  other  than  by  ex- 
pressing their  use. 
Ten  YEARS: 

Knows  money  values. 

Repeats  six  numerals. 

Gives  intelligent  answers  to  simple  questions 
involving  thought;  for  example,  "What 
would  you  do  if  a  playmate  struck  you 
accidentally?" 

In  suggesting  these  simple  tests,  that  can  be 
made  by  the  mother  in  the  home  without  the  use 
of  apparatus,  Stearns  says:^  "Failure  to  re- 
spond to  these  tests  .  .  .  must  be  explained. 
Taken  in  conjunction  with  slow  development  in 
other  things,  they  point  toward  permanent  limi- 
tation of  the  possibility  of  intellectual  develop- 
ment. Alone,  they  show  that  something  is 
wrong,  mental,  physical,  or  educational." 

As  children  grow  older,  progress  in  school  is 
significant  evidence  of  mental  development.  A 
delay  of  a  single  year  in  passing  to  the  next 
grade  deserves  consideration,  and  two  or  more 
years'  retardation  is  serious.    If  there  are  no 

^  A.  Warren  Stearns,  '"Practical  Mental  Examinations  for 
Growing  Children,"  No.  14  in  List  of  Publications,  p.  332. 

48 


MENTAL  EXAMINATION 

physical  conditions  interfering  with  the  child's 
progress,  such  retardation  points  to  the  desira- 
bility of  special  training  adapted  to  the  needs 
cf  the  individual  child. 

Borderline  cases  often  escape  observation  be- 
cause some  mental  defectives  manifest  qualities 
of  affection  and  amiability  which  cause  their 
deficiencies  to  be  overlooked.  A  child  may  be 
sub-normal  in  only  one  or  two  respects,  and  if 
these  happen  not  to  affect  the  standards  of  effi- 
ciency that  are  expected  of  him,  they  are  liable 
to  be  neglected.  If,  however,  they  are  moral 
defects  or  such  as  affect  his  ability  to  gain  a 
livelihood,  they  will  more  easily  be  discovered. 

Unrecognized  mental  deficiency  in  malnour- 
ished children  will  sometimes  explain  the  fail- 
ure to  get  results  in  cases  which  appear  to  be 
**free  to  gain."  If  a  child  is  mentally  deficient, 
there  is  always  the  possibility  that  one  of  the 
parents  is  likewise  defective,  and  in  this  case 
untrustworthy  and  misleading  reports  will  be 
given  as  to  the  carrying  out  of  directions.  A 
family  of  this  sort,  with  several  members 
slightly  defective,  may  take  up  the  time  of 
social  workers  from  various  institutions  with 
little  or  no  result.  The  mother  will  passively 
accept  advice,  but  do  nothing,  rendering  num- 
berless visits  to  the  home  necessary. 

49 


NUTRITION  AND  GROWTH  IN  CHILDREN 

A  study  of  the  economic  background  and 
social  relations  of  each  child  is  important  in  de- 
termining accurately  his  mental  as  well  as  his 
physical  condition.  Such  an  investigation  we 
call  the  social  examination. 


CHAPTER  VI 

THE  SOCIAL  EXAMINATION 

After  the  physical  defects  have  been  discov- 
ered through  the  physical-growth  examination, 
and  the  child's  mental  condition  has  been  in- 
vestigated, the  social  examination  is  brought  to 
bear  on  those  factors  that  are  concerned  with 
the  four  remaining  causes  of  malnutrition, 
namely : 

Lack  of  home  control 

Overfatigue 

Improper  diet  and  faulty  food  habits 

Fauhy  health  habits 

The  history  record  already  described  is  the 
first  source  of  social  information,  and  often 
gives  useful  hints  about  the  organization  of  the 
home  and  the  kind  of  control  that  prevails  there. 
This  must  be  expanded  by  a  careful  investiga- 
tion of  the  child's  life  during  the  entire  24 
hours,  and  a  diagnosis  cannot  be  complete  that 
considers  only  a  part  of  that  time.  As  many 
of  the  causes  of  malnutrition  exist  merely  be- 
cause they  are  unrecognized,  it  is  futile  to  at- 
tempt   treatment    without    securing    complete 

51 


NUTRITION  AND  GROWTH  IN  CHILDREN 

data  as  to  the  food  and  health  habits  of  the 
child  and  all  the  conditions  that  may  be  causing 
overfatigue. 

The  48-Hour  Record. — A  record  of  the  child's 
interests,  activities,  and  occupations  for  two 
consecutive  days,  with  a  detailed  list  of  all  food 
taken  during  the  same  period,  is  the  best  ap- 
proach to  a  thorough  understanding  of  the  so- 
cial causes  of  malnutrition.  A  single  day  may 
be  exceptional,  but  a  schedule  covering  two  con- 
secutive days  will  give  a  fair  average  of  the 
usual  routine.  Friday  and  Saturday  are  good 
days  to  select  because  they  will  show  the  out- 
side activities  as  well  as  the  school  schedule. 

In  order  to  gain  a  true  knowledge  of  the 
child's  habits  this  first  record  should  be  taken 
before  any  suggestions  are  made  for  their  im- 
provement. It  is  usually  a  surprise  even  to  well 
informed  and  observant  parents  to  face  this 
record  in  black  and  white,  and  it  becomes  ob- 
vious at  once  that  changes  are  needed. 

The  following  schedules  are  typical  of  condi- 
tions appearing  constantly  in  our  nutrition 
classes : 

A  Private  School  Boy  Who  Bolted  his  Breakfast 

Daniel  C,  6  to  7 :  30  reads  in  bed ;  7 :  30  rises ;  break- 
fast 7:  45;  bus  to  school  at  8;  in  school  8:30  to 
52 


Figure  12. 


HEREDITY  IS   NOT  USUALLY   THE  CAUSE  OF 
MALNUTRITION 


Mary  nnd  Alice  are  twins.      At   birth   Mary   weished   ^'^    pounds,   and 
Alice,   av^    pounds.     Now.   at   ttio  asre  of   nine   yoars.    Mary   wnighs    14 
pounds   more    than    Iier   sister   because   Alice   omitted    milk    and    cereal 
from  her  diet.     Mary  has  also  outstripped  Alice  in  height. 


SOCIAL  EXAMINATION 

12 ;  half  hour  recess  for  lunch ;  12 :  30  to  2  in 
school ;  2  to  4  supervised  play ;  home  at  4 :  30  with 
lunch  on  arrival;  5  to  6  reading  or  games;  6  to 
6 :  30  supper ;  6 :  30  to  8  home  study ;  retires  at 
8:30. 

The  hour  and  a  half  of  reading  in  bed  and  the 
hurried  breakfast  made  a  bad  start  for  the  day, 
which  was  not  offset  by  the  advantages  of  an 
open-air  school.  The  boy  failed  to  gain  until 
both  these  habits  were  corrected. 

Too  Much  Indoor  Occupation 

Dorotliy  S.,  rises  at  7 ;  breakfast  7 :  30 ;  school  at  8 :  30 ; 
recess  10 :  30 ;  home  for  dinner  at  12 ;  school  at 
1 ;  out  of  school  at  3 :  30 ;  Hebrew  lessons  4  to  6 
every  day  except  Friday  and  Saturday;  supper 
at  6 ;  assists  with  housework,  studies  lessons,  goes 
to  bed  at  9. 

This  girl  was  on  the  waiting  list  at  a  neighbor- 
ing settlement  to  take  piano  lessons  as  soon  as 
there  was  a  vacancy.  With  such  continuous  in- 
door occupation  it  was  not  surprising  that  Doro- 
thy was  sent  to  the  nutrition  class  from  a  tubercu- 
losis clinic. 

Irregular  Meals  and  Late  Hours 

James  (?.,  5  to  7  rises,  chores,  breakfast;  7  to  8:30 
trip  to  next  town  and  half  mile  walk  to  rural 
high  school ;  8 :  30  to  12  in  school  with  15-minute 
recess  at  10 :  15 ;  12  to  12 :  30  cold  lunch  eaten  in 
basement  with  other  boys ;  12 :  30  to  2  in  school ; 
53 


NUTRITION  AND  GROWTH  IN  CHILDREN 

2  to  4  return  trip  home  with  cold  lunch  on  ar- 
rival ;  4 :  15  to  7  chores  and  supper ;  7  to  9 :  30  or 
10  reading,  games,  study,  or  moving  pictures; 
9:30or  10  to5  sleep. 

A  Fifteen- YEAR-OLD  Girl  with  a  Sixteen-hour 
Schedule 

Isabel  B.,  5 :  30  or  6  to  7:15  rises,  breakfast,  gets 
ready  for  school;  7: 15  to  8:  30  walks  15  minutes 
to  car  line,  30-minute  ride  on  car,  walks  five 
blocks  to  school ;  8 :  30  to  12 :  15  in  school ;  12 :  15 
to  12:45  recess  and  lunch;  12:45  to  2:15  in 
school ;  2 :  15  to  3 :  30  return  trip  home  with  cold 
lunch ;  4  to  6  delivers  milk  to  three  neighbors,  all 
on  separate  trips,  making  a  walk  of  four  miles; 
6 :  30  to  7 :  30  supper,  washes  and  wipes  dishes 
for  eight  persons ;  7 :  30  to  9 :  30  studies  lessons ; 
9 :  30  to  5 :  30  or  6  sleep. 

The  advantage  of  making  these  records  is 
evident.  No  one  concerned  in  the  care  of  these 
children  had  any  idea  how  much  they  were  at- 
tempting to  crowd  into  the  child's  day.  A 
study  of  the  daily  program  of  almost  any  boy 
or  girl  reveals  similarly  unsuspected  demands 
upon  the  child's  energy. 

Overfatigue. — After  analyzing  the  48-hour 
record,  further  questions  may  be  necessary  to 
bring  out  the  facts  relating  to  overfatigue,  such 
as:  What  part  of  the  child's  day  is  given  to 

54 


SOCIAL  EXAMINATION 

play,  to  work,  and  to  school?  How  long  is  he 
actually  in  bed?  How  much  of  that  time  is  he 
asleep?  Has  he  learned  to  rest  when  not  sleep- 
ing? What  time  does  he  go  to  bed?  Does  he 
rise  in  time  to  get  to  school  promptly  without 
hurry  or  worry? 

Home  Conditions. — What  are  the  require- 
ments made  upon  the  child  as  a  member  of  the 
family  or  household?  Does  he  receive  too  much 
attention  from  older  people?  Does  he  receive 
enough?  Does  he  like  to  play  alone?  Who  are 
his  chosen  associates?  WTiat  are  his  favorite 
forms  of  recreation?  How  is  he  punished?  Is 
he  obedient?  What  regular  engagements  has 
he  in  the  way  of  scout  duties,  clubs,  music  or 
dancing  lessons,  gymnastic  training,  lessons  in 
foreign  languages  or  religion? 

Food  Habits. — What  is  the  average  number 
of  minutes  spent  at  each  of  his  meals?  Wliat 
are  the  interests  that  hurry  him  away  from 
the  table?  Does  he  wash  down  his  food  with 
liquids?  Does  he  drink  tea,  coffee,  ice  water? 
How  much  money  does  he  have  to  spend  for 
candy?  Has  he  any  marked  likes  or  dislikes 
in  the  way  of  food? 

Health  Habits. — How  much  of  the  child's 
day  is  spent  in  the  open  air?  Wliat  are  his 
sleeping  conditions  with  reference  to  open  win- 

55 


NUTRITION  AND  GROWTH  IN  CHILDREN 

dows,  drafts,  light,  etc.?  Does  he  sleep 
alone?  Is  he  disturbed  by  other  members  of 
the  family  who  retire  later  or  rise  earlier? 
Does  he  have  a  movement  of  the  bowels  at  a 
regular  time  every  day?  Does  he  get  his  feet 
wet?    How  often  does  he  bathe? 

The  New  Program. — A  careful  study  of  the 
replies  to  these  questions  will  throw  light  on 
many  possible  causes  of  the  child's  malnutri- 
tion, and  suggest  treatment  for  their  removal. 
In  making  up  the  daily  program  as  few  changes 
as  possible  should  be  made,  and  these  with  full 
consideration  for  the  tastes  and  prejudices  of 
the  child  in  order  that  progress  may  be  made 
along  the  lines  of  least  resistance.  The  really 
wrong  conditions  should  be  determined,  and  all 
the  force  that  can  be  brought  to  bear  focused 
upon  their  correction;  but  too  much  interfer- 
ence in  unimportant  details  will  only  defeat  the 
main  purpose,  which  is  to  make  sure  that  the 
essentials  of  health  are  obtained. 

The  new  program  should  be  checked  up  by  a 
48-hour  record  each  week.  "Where  the  children 
meet  in  nutrition  classes,  individual  conferences 
following  the  class  meeting  will  afford  op- 
portunity for  securing  further  information,  and 
these  may  be  supplemented  by  home  visits 
where  necessary. 

56 


SOCIAL  EXAMINATION 

Foster  Homes. — The  48-hour  records  have 
proved  especially  useful  in  the  supervision  of 
children  placed  in  foster  homes.     In  a  class 


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Figure  13.    an  ttnhappy  home 

Cynthia  slowly  gained  in  weight  nntil  tlie  ei^lith  week,  when  she 
became  unhappy  in  her  foster  home.  This  caused  a  loss  of  appetite 
with  a  consequent  loss  in  weight.  At  the  end  of  the  twelfth  week 
she  was  transferred  to  another  home  where  she  was  happy.  Her 
appetite  at  once  improved,  she  gained  rapidly,  and  in 
19  weeks  went  well  "over  the  top." 

composed  entirely  of  older  children  from  such 
homes  one  of  the  girls  continued  to  remain  at 
the  foot  of  the  class,  although  there  was  no 
evident  reason  for  her  marked  loss  of  weight. 
She  was  taking  sufficient  food  to  gain,  2,400 

57 


NUTRITION  AND  GROWTH  IN  CHILDREN 

calories,  and  the  foster  mother  could  appar- 
ently offer  no  explanation.  When  the  child  was 
questioned  by  herself,  however,  as  to  just  what 
she  did  each  hour  of  the  day,  she  suddenly 
broke  down  and  disclosed  a  schedule  that  might 
well  have  been  taken  from  a  tale  of  Dickens. 
This  underweight,  malnourished  girl  of  twelve 
had  been  compelled  to  do  the  washing  and  iron- 
ing for  a  family  of  five,  together  with  much 
other  heavy  work,  and  had  been  threatened  with 
punishment  if  she  should  tell  what  she  was 
doing.  The  state  worker,  after  verifying  the 
girl's  account,  transferred  her  to  a  better  home, 
where  an  immediate  gain  in  weight  showed  the 
quick  response  to  proper  treatment. 

This  is,  of  course,  an  extreme  case.  Yet  in- 
stances are  not  rare  of  ambitious  and  conscien- 
tious children  in  what  are  considered  the  best 
homes  overworking  themselves  without  pres- 
sure from  either  parents,  or  teachers — playing 
too  hard,  studying  too  hard,  or  working  too 
hard. 

Summary  o£  a  Social  Investigation. — In  a 
large  group  of  children  who  came  under  our 
observation  after  having  been  previously  under 
the  care  of  visiting  nurses  and  social  workers 
for  a  considerable  period  of  time,  we  found  72 
per  cent  still  using  tea,  coffee,  or  both;  64  per 

58 


SOCIAL  EXAMINATION 

cent  keeping  late  hours ;  28  per  cent  taking  in- 
sufficient food ;  36  per  cent  eating  too  fast ;  and 
54  per  cent  suffering  from  overfatigue  due  to 
extra  work  in  clubs,  classes,  church,  or  indus- 
try. Several  children  in  the  group  had  scarcely 
a  free  half-hour  in  the  whole  week. 


PART  II 

MALNUTRITION 
AND  THE  HOME 


CHAPTER  VII 

THE  ESSENTIALS  OF   HEALTH 

The  growing  child  requires  open  air,  suffi- 
cient food  for  growth,  adequate  exercise,  and 
proper  rest.  Yet  with  all  these  requirements 
provided,  many  children  nevertheless  fail  to 
develop  properly  and  become  seriously  mal- 
nourished. Open  air  will  not  help  the  child 
unless  ho  can  breathe  it  freely  into  the  lungs. 
Sufficient  food  may  be  available,  and  it  usually 
is,  but  if  food  habits  are  wrong  he  will  still  be 
undernourished ;  it  is  not  so  much  what  a  child 
eats,  but  what  he  assimilates,  that  promotes  his 
growth.  He  may  have  opportunity  for  exer- 
cise and  rest,  but  unless  properly  employed, 
these  in  turn  fail  to  insure  normal  growth  and 
health. 

To  overcome  all  obstacles  in  the  way  of  the 
child's  progress,  as  indicated  by  the  foregoing 
discussion  of  the  causes  of  malnutrition,  a 
comprehensive  program  must  be  adopted  that 
includes  all  the  essentials  of  health.  Reduced  to 
their  simplest  terms,  these  may  be  re-stated  as 
follows : 

63 


NIJTEITION  AND  GROWTH  IN  CHILDREN 


1.  The  removal  of  physical  defects 

2.  Sufficient  home  control  to  insure  good  food  and 
health  habits 

3.  The  prevention  of  overfatigue 

4.  Proper  food  at  regular  and  sufficiently  frequent 
intervals 

5.  Fresh  air  by  day  and  by  night 


Home 

/ 

ThG 

-School 

The  chl  ds  health 

Medical 
Care 

Child's  own  interest 

\ 

FlGTIEE    14.      THE   PA31AIXEL0GRAM    OF   FOBCES    THAT    SATEGUABD 
THE  child's  health 

An  analysis  of  this  list  makes  it  apparent 
that  the  necessary  conditions  can  be  readily  es- 
tablished provided  all  forces  that  control  the 
child's  health  are  brought  into  cooperation. 
These  controlling  factors  fall  into  four  groups, 
constituting  a  parallelogram  of  forces  that 
safeguard  the  health  of  the  child. 

64 


ESSENTIALS  OF  HEALTH 

The  first  factor  is  the  Home;  the  second  in- 
cludes those  relations  that  are  Medical  in  na- 
ture ;  the  third  group  consists  of  the  School  and 
other  social  organizations;  while,  connecting 
and  uniting  them  all,  is  the  fourth  force,  the 
Child's  Own  Interest.  Disregard  of  any  one  of 
these  four  forces  may  defeat  what  the  others 
might  accomplish,  w^hile  a  program  that  takes 
full  account  of  them  all  insures  rapid  improve- 
ment in  health  and  growth. 

A  well  organized  nutrition  class  is  the  best 
agency  for  coordinating  these  forces  in  a  pro- 
gram that  provides  a  common  appeal.  Start- 
ing with  a  thorough  physical  examination,  it 
undertakes  to  secure  the  cooperation  of  the 
home  in  carrying  out  the  recommendations  of 
the  physician.  Where  school  pressure  is  inter- 
fering with  the  child's  progress,  it  assists  the 
parent  in  securing  a  modification  of  the  school 
program  or  such  an  adjustment  of  its  schedule 
as  will  remove  the  occasion  of  overfatigue.  By 
showing  the  needs  of  the  malnourished  chil- 
dren, and  recommending  their  separation  from 
the  regular  class  until  they  are  brought  up  to 
normal  condition,  it  aids  the  school  in  maintain- 
ing its  standards  for  the  children  who  are  well. 
The  nutrition  class  also  arouses  the  child's  own 
interest  so  that  he  is  willing  to  ''train  for 

65 


NUTRITION  AND  GROWTH  IN  CHILDREN 

health"  and  enter  heartily  into  the  plans  made 
for  his  improvement. 

The  Home. — It  is  discouraging  for  a  mother 
who  has  reorganized  her  home  life,  planned  for 
lunches  and  rest  periods,  and  in  every  way  made 
a  business  of  caring  for  her  child,  to  find  that 
something  outside  the  walls  of  her  home  is 
blocking  his  progress.  Thousands  of  children, 
it  is  true,  are  being  made  well  by  the  earnest 
and  intelligent  efforts  of  mother  and  child  work- 
ing together  with  little  outside  help ;  but  unfor- 
tunately it  is  also  true  that  many  of  the 
best  home  programs  fail  because,  however 
strong  the  chain  that  the  mother  has  forged, 
there  are  essential  links  beyond  her  im- 
mediate control  that  break  with  any  sudden 
strain. 

The  School. — In  one  instance,  the  child  fails 
to  gain  because  of  long  school  hours  or  too  short 
an  intermission  at  noon.  In  another,  the  trou- 
ble is  caused  by  the  demands  of  clubs  or 
other  associations  that  it  seems  desirable  the 
child  should  maintain.  Even  progress  as  a 
Boy  or  Girl  Scout,  or  confirmation  in  church,  re- 
quires extra  study  in  a  program  already  full  to 
overflowing.  The  mothers  and  their  children 
may  be  genuinely  interested  in  health,  but  there 
is  a  conflict  between  the  health  essentials  and 

66 


ESSENTIALS  OF  HEALTH 

these  other  interests  that  calls  for  adjustment 
and  compromise. 

Every  mother  is  forced  to  recognize  these 
claims.  Some  look  upon  them  as  occasions  for 
irritation,  to  be  resisted  as  far  as  possible, 
while  others  are  unwisely  ready  to  give  over  the 
power  of  decision  to  the  school  or  social  worker 
concerned,  or  even  to  the  child  himself.  The 
central  responsibility,  however,  must  remain 
with  the  parents,  and  when  they  call  in  the  aid 
of  any  special  worker  or  organization,  they  must 
see  that  the  new  activity  fits  in  with  the  rest 
of  the  child's  program;  otherwise,  instead  of 
being  better  off  from  the  new  association,  he 
may  be  merely  the  victim  of  added  and  conflict- 
ing pressure. 

Medical  Care. — Many  child-helping  agencies 
whose  efforts  are  well  directed  along  one  or 
more  lines  fail  to  secure  substantial  results  be- 
cause they  do  not  recognize  the  inter-relation 
of  these  forces  in  the  child's  life.  This  is,  per- 
haps, most  true  in  the  case  of  medical  care, 
which  is  an  essential  feature  of  the  nutrition 
class  program.  More  children  are  kept  from 
normal  development  by  not  being  "free  to 
gain"  than  by  any  other  single  cause.  Ob- 
structions to  breathing  and  other  physical  de- 
fects are  handicaps  that  offset  the  good  that 

67 


NUTRITION  AND  GROWTH  IN  CHILDREN 

might  otherwise  result  from  careful  instruc- 
tion in  food  and  hygiene.  A  complete  physical 
examination  is  the  only  sure  method  of  deter- 
mining the  medical  causes  of  malnutrition,  and 
no  program  that  disregards  this  factor  can 
hring  about  more  than  transitory  improvement. 
The  Child's  Own  Interest. — It  is  not  neces- 
sary to  remind  parents  or  teachers  that  chil- 
dren willingly  exert  themselves  for  something 
in  which  they  are  interested,  while  it  is  impos- 
sible to  bring  their  forces  into  action  when  they 
feel  no  concern  in  the  object  to  be  attained.  As 
the  malnourished  child  is  frequently  a  *' diffi- 
cult" child,  and  the  carrying  out  of  the  health 
program  demands  both  perseverance  and  self- 
sacrifice  on  his  part,  it  will  be  seen  how  im- 
portant it  is  to  arouse  his  own  interest  in  his 
health  and  to  secure  his  cooperation.  In  the 
nutrition  class  the  weight  charts  visualize  the 
progress  made  and  stimulate  the  children  to  a 
healthy  spirit  of  competition ;  while  the  failure 
of  those  who  do  not  follow  directions,  as  well  as 
the  success  of  those  who  do,  serves  as  a  con- 
vincing demonstration  to  the  whole  group,  and 
secures  their  cooperation  and  hearty  support. 


CHAPTER  VIII 

HOME   CONTROL 

Malntjtbition  can  often  be  traced  to  faulty 
home  conditions,  and  in  all  cases  the  home  is  an 
essential  factor  in  successful  treatment.  The 
physician  can  outline  the  important  points  of  a 
health  program,  but  its  success  will  be  in  pro- 
portion to  the  degree  of  cooperation  with  which 
it  is  carried  out  by  parent  and  child.  It  is  well 
to  consider  what  is  the  prevailing  atmosphere 
of  the  home.  Is  it  positive  or  negative,  a  place 
of  hope  and  stimulation  or  one  of  repression 
and  fear?  Does  its  tone  indicate  hurry,  injus- 
tice, worry,  deception,  or  the  opposite  of  these 
undesirable  qualities?  Do  the  children  hear 
constantly,  ''Don't  do  this,"  and  ''Don't  do 
that,"  or  are  they  encouraged  to  try  things  out 
for  themselves  with  a  minimum  of  caution,  but 
with  help  given  freely  when  necessary? 

Home  conditions  affect  all  children,  but  they 
are  of  special  significance  in  the  lives  of  the 
malnourished.  Good  government  in  the  home, 
as  in  the  state,  makes  for  happiness  and  health, 
and  the  principle  of  self-government  will  bring 

69 


NUTRITION  AND  GROWTH  IN  CHILDREN 

about  surprising  results  in  the  matter  of  health 
once  the  child's  own  interest  is  aroused,  and  his 
attention  directed  to  the  subject  intelligently. 

Training  for  Health. — There  is  powerful 
suggestion  for  good  in  such  slogans  as  the  Boy 
Scout  phrase,  "Be  prepared."  Children  are 
natural  hero-worshipers,  and  the  desire  to  be  a 
good  athlete,  or  to  excel  in  games  or  other  ac- 
complishments admired  in  others,  will  make 
many  a  boy  and  girl  willingly  accept  self-dis- 
cipline that  could  not  easily  be  imposed  on  them 
by  others.  Appeal  should  be  made  to  the  child's 
ideals  through  the  reading  of  tales  of  hardi- 
hood and  vigor.  Nothing  counts  for  more  than 
the  painting  of  mental  pictures  that  reveal  the 
possibilities  of  strength,  force,  and  health  in 
such  vivid  colors  that  the  child  will  be  inspired 
to  make  them  realities  in  his  own  case.  The 
child  must  be  made  to  take  a  personal  interest 
in  his  health.  He  should  not  follow  the  health 
program  merely  as  a  matter  of  routine  and  obe- 
dience, but  should  be  so  convinced  of  its  value 
that  no  external  discipline  is  needed  to  make 
him  carry  it  out. 

This  has  been  exemplified  in  numerous  cases 
in  our  nutrition  classes.  One  child  will  remind 
a  forgetful  mother  of  the  time  for  lunches  and 
rest  periods;  another  will  ask  for  more  air  in 

70 


Figure  15. 


A   niFFKREXCE   OF   FI\"E   YEARS   IN    AGE   AND  OF 
FOUR   POUNDS   IN    WEIGHT 


Paul  Is  eight  years  old  and  weighs  S3  pounds;  liis  brother  Ralph  is 
three,  and  weighs  liD  pounds.  Paul  is  stunted  botli  in  height  and  in 
weight  beeruse  of  improper  food  habits.  The  nutrition  worker  found 
that  he  was  tal<ing  less  food  than  tliat  required  by  an  infant  of  one 
year.  lie  did  not  like  milk,  bread,  butter,  fish,  or  meat  ;  he  washed 
his  food  down  with  liquids  ;  and  he  was  allowed  to  sit  at  the  table  and 
play  with  his  food  while  the  others  were  eating.  His  mother  says  he 
is  "irritable  and  cranky."  Ualph.  on  the  other  hand. 
Is  strong,  good-natured,  and  happy. 


HOME  CONTROL 

the  sleeping  room;  others  give  up  tea  and  cof- 
fee, and  teach  themselves  to  like  foods  to 
which  they  previously  had  an  antipathy.  Chil- 
dren even  persevere  in  their  eiforts  when  the 
cooperation  of  the  home  is  lacking,  or  when  un- 
able to  continue  attendance  at  the  classes. 
After  the  summer  vacation  many  reports  of 
good  gains  are  brought  in  to  the  clinic.  In  one 
case,  a  girl  of  13  who  had  been  absent  over  a 
year  gained  15  pounds  and  came  to  claim  her 
certificate,  which  she  had  won  by  her  own  efforts 
while  her  mother  was  away  from  home. 

Winning  the  Child's  Confidence. — There  is 
nothing  of  greater  importance  to  a  child  than 
to  feel  that  he  is  understood.  The  wise  mother 
knows  when  a  child  is  over-taxed,  and  makes 
proper  allowance  for  him.  She  realizes  that  his 
disposition  changes  under  stress,  and  says, 
truly,  "He  is  not  himself."  She  studies  to 
recognize  the  occasions  on  which  this  is  a  valid 
excuse,  and  tries  to  find  the  cause  and  remove  it. 

A  frequent  cause  of  malnutrition  is  found  in 
the  child's  feeling  that  he  has  been  unjustly 
treated,  and  the  fact  that  he  may  be  mistaken 
makes  the  result  no  less  serious.  If  the  weekly 
weighing  is  made  something  of  a  ceremony,  and 
the  child  sees  that  both  parents  are  really  in- 
terested in  his  condition,  he  will  respond  with 

71 


NUTRITION  AND  GROWTH  IN  CHILDREN 

an  unusual  degree  of  confidence.  It  is  impor- 
tant to  find  out  what  the  child  really  cares  for 
and  fears.  Some  trifling  matter  may  be  caus- 
ing a  distress  that  interferes  with  normal 
growth.  Counter-suggestion,  it  should  be  re- 
membered, is  much  more  effective  than  repres- 
sion, and  it  has  only  recently  been  recognized 
how  much  fear,  apprehension,  and  distress  in 
later  life  are  due  to  repression  in  childhood. 

The  Correction  of  Bad  Sex  Habits.— Many 
mothers  are  much  concerned  about  the  effect 
upon  the  children's  health  of  bad  sex  habits. 
This  is  naturally  a  matter  about  which  it  is  not 
difficult  to  have  misunderstanding.  A  feeling 
of  delicacy  and  reticence  often  leads  to  sus- 
picions that  read  into  some  simple  statement  or 
act  much  more  than  belongs  to  it.  It  is  easy  to 
look  at  these  matters  from  an  excessively  moral 
standpoint,  and  to  fail  to  see  the  normal  physi- 
cal and  mental  aspects  that  may  need  attention. 
Boys  and  girls  are,  on  the  whole,  a  level-headed 
lot,  and  they  usually  understand  such  matters 
in  a  healthy  way. 

With  a  little  child  a  tendency  to  masturbation 
should  be  met  in  the  same  manner  that  one 
would  deal  with  biting  finger  nails  or  sucking 
thumbs.  It  may  require  some  simple  punish- 
ment to  prevent  the  formation  of  this  habit,  but 

72 


HOME  CONTROL 

the  child  should  not  be  led  to  focus  attention 
upon  the  subject. 

An  older  child  suffers  more  from  the  effects 
of  worry  about  what  he  fears  may  be  wrong 
than  from  any  other  cause.  This  worry  is  often 
serious,  and  the  air  of  mystery  and  secrecy 
with  which  adults  treat  the  subject  only  makes 
a  bad  matter  worse.  It  may  be  comforting  to 
parents  to  know  that  in  a  most  careful  investi- 
gation that  we  have  made  recently  we  have 
not  found  a  single  instance  in  which  bad  sex 
habits  had  caused  malnutrition.  Among  men- 
tally deficient  children,  the  presence  of  these 
habits  is  an  effect  of  their  mental  condition,  and 
is  rarely,  if  ever,  the  cause. 

Selfishness  in  Parents  and  Children. — Much 
of  the  self-indulgence  that  wastes  a  child's  life 
grows  out  of  the  self-indulgence  of  older  peo- 
ple. The  mother  who  lets  her  child  ''have  his 
own  way"  is  often  gratifying  her  own  pleasure. 
By  making  a  pet  of  him  she  seeks  to  make  him 
dependent  solely  on  her  for  his  happiness  and 
comfort.  She  encourages  him  to  come  to  her 
with  little  ailments  and  symptoms,  and  sympa- 
thizes with  his  sensitiveness  instead  of  teach- 
ing him  to  meet  small  hurts  and  disappoint- 
ments with  self-control.     The  problem  of  the 

73 


NUTRITION  AND  GROWTH  IN  CHILDREN 

spoiled  child  is  too  often  the  problem  of  the 
spoiled  mother. 

The  thought  that  even  little  children  can  do 
something  helpful  for  other  members  of  the 
family  will  do  away  with  many  tendencies  to- 
wards selfishness.  The  child  should  be  encour- 
aged in  the  normal  wish  to  help  by  having  his 
activity  directed  into  useful  avenues.  His  de- 
sire to  be  useful  begins  to  show  itself  when  his 
actual  accomplishment  amounts  to  little,  but  his 
attempts  should  nevertheless  be  encouraged. 
The  failure  to  help  later  when  his  work  would 
be  worth  more  may  be  due  to  the  fact  that  the 
earlier  impulse  was  not  turned  into  a  habit  of 
helpfulness. 

Self-reliance  and  readiness  to  cooperate 
furnish  the  best  basis  for  health  as  well  as  for 
happiness.  The  child  should  be  taught  to  as- 
sume responsibility  from  his  earliest  years. 
Apart  from  the  value  of  the  service,  there  is  the 
importance  to  him  of  having  a  constructive  and 
responsible  attitude  towards  life.  How  many 
parents,  instead  of  giving  the  child  the  needed 
instruction,  will  say,  "I'd  rather  do  it  myself 
than  be  bothered  with  him. "  On  the  other  hand, 
it  is  possible  to  go  too  far  in  this  direction,  and 
to  lay  burdens  upon  a  child  heavier  than  his 
strength  should  bear. 

74 


HOME  CONTROL 

Many  cases  of  malnutrition  are  a  direct  re- 
sult of  over-indulgence  for  which  the  ''spoiled 
child"  pays  a  heavy  penalty.  The  malnour- 
ished child  is  apt  to  be  the  only  child,  or  else 
the  youngest  or  the  oldest — the  ''pet"  who  has 
got  the  upper  hand  of  the  father  and  the  mother. 
It  is  evident  in  many  homes  that  the  child  is  in 
control,  and  the  parent  his  willing  or  unwilling 
slave.  If  he  does  not  wish  to  do  a  thing,  he  has 
no  idea  that  there  is  any  reason  why  he  should, 
or  any  power  to  compel  him.  Nothing  can  be 
accomplished  in  such  a  home  until  it  is  made 
clear  that  there  is  some  one  besides  the  child 
who  is  directing  the  course  of  his  program. 

The  tendency  to  undue  self-assertiveness  ap- 
pears naturally  at  a  certain  age,  and  would  soon 
disappear  if  properly  met  and  handled.  Dis- 
plays of  temper  are  usually  practiced  because 
they  have  proved  a  successful  means  of  getting 
what  the  child  wants.  If  encouraged  in  his  de- 
fiance of  authority,  he  may  become  saddled  for 
life  with  a  disagreeable  and  unfortunate  habit. 

The  Influence  of  Suggestion  and  Competi- 
tion.— Malnourished  children  are  especially  sus- 
ceptible to  suggestion,  and  fears  once  impressed 
upon  them  are  almost  impossible  to  eradicate. 
Their  condition  should  always  be  spoken  of 
hopefully  in  their  presence.     They  should  be 

75 


NUTRITION  AND  GROWTH  IN  CHILDREN 

impressed  with  the  fact  that  it  is  normal  to  be 
well,  and  should  not  be  allowed  to  think  of  them- 
selves as  invalids. 

Among  the  poor  we  find  many  children  who 
are  kept  from  normal  growth  by  worry  over  the 
payment  of  rent,  the  care  of  younger  children, 
the  fear  of  the  father's  losing  his  job.  Even 
in  the  homes  of  the  well-to-do,  young  children 
come  to  know  too  much  about  the  anxieties  and 
difficulties  that  oppress  their  parents.  They 
should  not  be  allowed  to  enter  into  the  discus- 
sion of  family  problems,  or  made  to  share  anx- 
iety over  conditions  that  they  cannot  help  to 
control. 

Perhaps  the  most  powerful  influence  in  a 
child's  life  is  the  approval  of  his  associates. 
He  is  quick  to  detect  what  is  considered  ''good 
form"  in  the  group  to  which  he  belongs,  or 
wishes  to  belong.  The  spirit  of  competition 
makes  a  strong  appeal,  and  a  boy  will  spur 
himself  on  to  achieve  what  others  of  his  group 
have  accomplished.  This  is  one  of  the  great 
advantages  of  association  in  nutrition  classes. 
But  even  when  the  child  is  alone,  he  has  his  own 
normal  weight  standard  with  which  to  compete, 
and  this  is  the  goal  that  will  help  to  enforce  the 
rest  periods,  extra  lunches,  early  hours,  and 
other  features  of  a  good  health  program. 

76 


HOME  CONTROL 

Punishment  Should  Be  Constructive.  —  It 
should  never  be  forgotten  tliat  punishment  is 
always  an  individual  problem.  A  little  study 
of  the  child's  nature  will  show  how  to  be  just 
and  fair  to  him,  and  only  on  that  basis  can  his 
respect  and  affection  be  retained.  The  right 
kind  of  punishment  tends  to  do  away  with  the 
necessity  for  its  repetition,  and  the  aim  should 
be  to  make  it  easier  for  the  child  to  do  what  is 
best  for  his  health  rather  than  to  ''have  his 
own  way"  and  do  himself  harm. 

Happiness  has  a  positive  health  value,  and 
wrong  methods  of  punishment  are  a  frequent 
cause  of  malnutrition.  In  the  ideal  home  there 
is  a  healthy,  normal  attitude  that  seems  to  keep 
the  child  away  from  acts  that  call  for  punish- 
ment. When  the  need  does  come,  it  should  be 
met  in  a  constructive  spirit,  with  no  evidence  of 
retribution  or  bad  temper. 

One  of  the  most  serious  cruelties  practiced 
upon  a  child  is  the  withholding  of  an  expected 
punishment  until  the  following  day.  Punish- 
ment should  be  prompt,  although  if  there  is  any 
reason  for  doubt,  justice  should  not  be  sacrificed 
to  promptness.  To  punish  justly  it  is  neces- 
sary to  know  the  reactions  of  the  individual 
child.  Unfortunately,  much  punishment  is 
given  as  a  matter  of  form,  with  little  more  than 

77 


NUTRITION  AND  GROWTH  IN  CHILDREN 

superficial  results,  and  many  mothers  show  a 
singular  lack  of  imagination  when  confronted 
by  a  situation  requiring  discipline. 

Physical  punishment  is  rarely  necessary,  and 
should  be  used  experimentally,  and  only  as  a 
last  resort.  When  it  is  really  needed  and  is 
well  used,  it  may  prove  very  effective. 

Sending  a  child  to  bed  without  supper  is  in- 
excusable, and  is  particularly  ill-advised  in  the 
case  of  the  malnourished  child.  On  the  other 
hand,  taking  away  privileges  is  a  sound  method 
of  discipline.  This  may  take  the  form  of  ad- 
vancing the  usual  bedtime  for  a  short  period, 
which  will  have  the  benefit  of  reducing  the 
child's  activities  and  increasing  his  time  for 
rest.  Especially  good  conduct  may  be  recog- 
nized by  shortening  the  time  of  the  early-to-bed 
sentence,  and  further  misdemeanor  punished 
by  extending  its  duration. 

Responsibility  of  the  Parents. — In  the  com- 
plicated conditions  of  modern  life  parenthood 
is  more  than  ever  an  art  calling  for  great  skill 
and  judgment.  Where  bad  control  has  existed 
for  some  time,  it  may  be  necessary  to  separate 
a  mother  and  child  for  a  short  period.  We  have 
had  many  cases  in  which  children  failed  to 
gain,  or  continued  to  lose,  while  under  the  care 
of  the  mother,  and  began  at  once  to  climb  to 

78 


HOME  CONTROL 

their  normal  weight  line  as  soon  as  an  aunt,  or 
cousin,  or  grandmother  took  them  in  charge. 
Similar  improvement  is  often  effected  when  the 
child  is  placed  in  a  well  organized  school. 

To  control  all  the  factors  affecting  the  health 
of  their  children  the  interest  of  the  parents 
must  extend  beyond  the  home  to  church,  school, 
playground,  club,  and  every  other  center  of 
their  activity  and  interest.  In  Chapter  I  we 
list  lack  of  home  control  as  one  of  the  principal 
causes  of  malnutrition,  but  it  is,  in  fact,  di- 
rectly or  indirectly  responsible  for  all  the 
others.  If  there  are  physical  defects  present, 
it  is  the  parents'  duty  to  see  that  they  are  re- 
moved; faulty  food  and  health  habits  must  be 
corrected  in  the  home ;  and  overfatigue,  whether 
from  work,  study,  or  play,  can  be  avoided  only 
by  the  watchful  supervision  of  thoughtful 
parents* 


CHAPTER  IX 

OVERFATIGUE 

Continued  experience  in  the  treatment  of 
malnutrition  leads  me  to  the  belief  that  there 
is  no  responsible  cause  for  this  condition  more 
frequently  overlooked  than  habitual  over- 
fatigue. It  is  hard  for  grown  people  to  realize 
how  many  and  how  wearing  are  the  activities 
of  the  child,  and  even  where  it  is  recognized  that 
the  child  is  overtired,  the  condition  is  assumed 
to  be  a  temporary  discomfort,  rather  than  a 
serious  cause  of  permanent  injury. 

Fatigue  and  Overfatigue. — It  is  necessary  to 
distinguish  between  the  fatigue  that  is  a  na- 
tural result  of  exertion,  from  which  there  is  a 
quick  recovery,  and  overfatigue,  which  carries 
the  child  each  time  farther  from  his  normal  con- 
dition, and  makes  his  return  to  health  more  dif- 
ficult. In  this  case  the  child  is  either  overstimu- 
lated  so  as  not  to  know  that  he  is  tired,  or  else 
he  has  a  disinclination  for  exertion  of  any  kind, 
and  a  feeling  of  being  dragged  out  and  ex- 
hausted. 

The  problem  of  overfatigue  has  been  one  of 
80 


OVERFATIGUE 

the  most  difficult  problems  of  the  physiologist. 
There  is  no  single  test  or  group  of  tests  that  will 
serve  as  an  accurate  measure  of  fatigue,  and 
we  must  be  guided  therefore  by  practical  obser- 
vation of  the  physical  condition  of  the  child  and 
his  reactions  to  his  various  tasks.  The  weight 
curve  is  the  most  valuable  test  available  to 
show  the  effect  of  fatigue.  If  the  child  fails  to 
gain  after  other  known  causes  for  his  loss  of 
weight  have  been  removed,  overfatigue  must 
always  be  suspected  as  the  cause  of  his  poor 
condition.  Usually,  a  modification  of  the  men- 
tal or  physical  program,  with  increased  rest 
periods,  will  bring  about  a  prompt  gain  and 
demonstrate  that  overfatigue  has  been  the  ob- 
stacle to  progress. 

No  one  experienced  in  the  care  of  animals 
allows  them  to  be  over-exercised  during  the 
growing  period.  A  valuable  colt  is  never  en- 
tered in  long  races  until  maturity,  and  it  is 
recognized  that  a  horse  can  be  killed  by  over- 
driving or  by  being  fed  immediately  after 
severe  exercise.  There  is  need  for  similar  cau- 
tion in  the  care  of  the  growing  child. 

Causes  of  Overfatigue. — There  are  a  thou- 
sand causes  of  overfatigue.  The  child  will  na- 
turally overdo,  and  the  brighter  and  more  active 
he  is,  the  greater  the  danger.    The  spirit  of 

81 


NUTRITION  AND  GROWTH  IN  CHILDREN 

competition  and  the  desire  to  stand  well  with 
his  associates  leads  him  to  undertake  tasks  far 
beyond  his  strength.  This  may  be  seen  most 
frequently  in  play,  where  many  a  child  is  led 
through  the  influence  of  his  comrades  to  enter 
into  contests  calling  for  both  mental  and  physi- 
cal endurance,  when  he  has  no  energy  to  spare 
for  such  strenuous  exertion. 

Adults  seldom  appreciate  how  much  energy 
and  strength  are  required  in  simply  growing. 
They  do  not  take  into  account  how  often  the 
child  is  over-taxed  in  trying  to  keep  up  with 
older  people,  not  only  in  walking,  for  example, 
but  in  adapting  himself  to  the  various  tools  and 
equipment  of  a  w^orld  that  is  designed  for 
grown-ups, 

A  written  record  of  the  child's  activities  for 
48  hours  will  surprise  almost  any  parent  in  its 
revelation  of  unnoticed  occasions  of  fatigue. 
This  is  especially  true  during  the  earlier  years. 
From  the  age  of  two  to  six  the  child  is  apt  to 
be  made  the  pet  of  the  family,  each  member  in 
turn  entertaining  him,  seldom  leaving  him 
alone,  and  often  interrupting  his  proper  rou- 
tine to  gratify  the  wish  to  be  with  him.  Spurred 
on  by  one  stimulus  after  another,  the  child  is 
tired  out  at  the  end  of  the  day,  but  may  have 
his  bedtime  delayed  for  the  father's  return, 

82 


OVERFATIGUE 

and  his  sleep  disturbed  again  in  the  morning 
so  that  the  father  may  see  him  before  leaving 
home. 

The  48-hour  record  (as  described  in  detail 
under  the  Social  Examination,  Chapter  VI) 
should  be  analyzed,  and  every  item  challenged 
to  see  if  it  is  a  necessary  tax  on  the  child's 
strength.  His  program  should  then  be  cor- 
rected so  as  to  provide  for  an  improved  expen- 
diture of  time  and  energy. 

Rest  and  Sleep. — The  amount  of  sleep  needed 
varies  with  the  individual,  but  every  malnour- 
ished child  should  spend  at  least  from  10  to  12 
hours  in  bed  every  night.  Some  get  their  best 
sleep  early  in  the  night,  while  others  sleep 
better  in  the  morning.  The  greater  number  of 
*' nervous"  children  seem  to  be  of  the  ''morn- 
ing" type.  The  same  individuality  is  evident 
in  all  forms  of  fatigue.  Each  child  has  his 
own  way  of  becoming  tired,  which  may  be  very 
unlike  that  of  other  members  of  the  family. 
The  same  cause  may  show  effect  in  various 
ways  and  in  different  parts  of  the  body. 
*' Nervous"  children  frequently  show  fatigue  by 
restlessness,  tossing  in  their  sleep,  and  night- 
mare. 

In  addition  to  the  night's  rest,  regular  rest 
periods  in  the  middle  of  the  morning  and  the 

83 


NUTRITION  AND  GROWTH  IN  CHILDREN 

middle  of  the  afternoon  are  recommended  for 
all  children  who  fail  to  gain  when  following  the 
nutrition  program,  and  whose  malnutrition  is 
found  to  be  the  result  of  overfatigue.  These 
rest  periods  have  the  effect  of  shortening  the 
periods  of  activity,  and  therefore  preventing 
further  fatigue,  while  the  rest  and  sleep  restore 
the  waste  of  past  activity.  The  rest  periods 
also  increase  the  child's  power  of  food  assimi- 
lation. Fatigue  interferes  with  absorption,  and 
the  child  will  benefit  in  both  appetite  and  diges- 
tion if  he  has  a  short  rest  before  eating. 

The  proper  position  for  the  rest  periods  is 
shown  in  Figure  16.  The  clothing  should  be 
loosened,  the  windows  open,  and  the  child 
should  face  away  from  the  light.  He  should 
not  be  allowed  to  take  either  books  or  toys 
to  bed  with  him.  Children  should  be  taught 
to  rest  even  when  not  sleeping,  although  the 
regularity  of  the  rest  periods  when  faithfully 
followed  seldom  fails  to  induce  sleep.  The 
rest  period  should  be  for  at  least  half  an  hour, 
but  20  minutes  of  complete  rest  are  worth  more 
than  an  hour  spent  tossing  about  in  discomfort. 
The  ability  to  sleep  for  short  periods  at  any 
time  is  a  habit  that  makes  for  health. 

In  extreme  cases,  absolute  rest  in  bed  for  sev- 
eral days  may  be  the  means  of  causing  the  first 

84 


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OVERFATIGUE 

gain.  In  other  instances,  it  will  be  better  for 
the  child  to  have  breakfast  in  bed  at  his  regular 
hour,  and  then  continue  to  rest  until  10  or  11 
o'clock.  He  should  not  be  allowed  to  sleep 
through  his  usual  breakfast  time,  and  thus  lose 
the  value  of  regular  meals. 

During  the  early  years  of  childhood  discre- 
tion should  be  used  in  story  telling  at  bedtime. 
At  the  age  of  four  or  five  the  imagination  is 
especially  active,  and  exciting  stories  often  af- 
fect the  child  painfully,  causing  fear  of  the  dark, 
of  unusual  sounds,  and  of  strangers.  The  child 
should  go  to  bed  happy  and  contented,  under 
conditions  that  assure  warmth  and  comfort,  and 
with  the  distinct  idea  of  going  to  sleep  at  once. 

As  light  is  a  powerful  sensory  stimulus,  there 
should  be  no  light  in  the  sleeping  room.  It  has 
been  demonstrated  that  the  depth  of  sleep  is 
much  greater  during  the  dark  nights  of  winter 
than  during  the  lighter  nights  of  summer. 
Children  should  not  be  permitted  to  sleep 
in  underclothing  that  has  been  worn  during  the 
day.  Their  sleep  should  not  be  disturbed  by 
the  later  retiring  or  earlier  rising  of  other  mem- 
bers of  the  family. 

Among  older  children  it  is  necessary  to  limit 
the  activities  that  tend  to  prolong  their  day. 
After  a  full  school  schedule,  with  home  study 

85 


NUTRITION  AND  GROWTH  IN  CHILDREN 

and  some  share  in  household  tasks  or  chores, 
it  is  natural  for  the  child  to  wish  to  have  some 
amusement  in  the  evening.  With  each  succeed- 
ing year  these  social  demands  increase  their 
pressure,  and  are  fraught  with  the  greatest  dan- 
ger for  those  children  who  are  below  normal 
weight.  A  short  vacation  filled  with  social  dis- 
tractions may  offset  the  gain  made  during  a 
whole  year.  Nearly  40  per  cent  of  all  malnour- 
ished children  keep  late  hours. 

The  Strain  of  School  Life. — It  is  difficult  to 
gage  or  measure  the  utter  fatigue  of  the  mal- 
nourished child  in  his  struggle  to  meet  stand- 
ards that  are  frequently  too  high  even  for 
those  who  are  well.  This  is  especially  the  case 
in  school  life,  where  our  very  efficiency  in  em- 
ploying the  spirit  of  competition  is  a  source  of 
peril  to  the  undernourished.  Children  are 
urged  on  by  such  slogans  as  ''Never  give  up" 
and  "Always  say,  'I'll  try,'  "  while  to  this  ap- 
peal to  pride  and  honor  their  comrades  add  the 
spur  of  "Don't  be  a  quitter." 

A  school  committee  chairman  of  long  expe- 
rience told  me  that  in  an  investigation  of  the 
causes  of  truancy  one  of  the  children  told  him 
he  stayed  away  from  school  because  he  "got 
tired  of  the  teacher's  voice."  This  child  was 
suffering  from  overfatigue,  and  if  this  condi- 

86 


OVERFATIGUE 

tion  had  been  better  realized  the  matter  of  his 
school  discipline  might  have  been  greatly  sim- 
plified. Few  adults  feel  equal  to  concentrated 
mental  effort  for  more  than  an  hour  or  two  at  a 
time,  yet  many  schools  expect  three  and  four 
hours  of  continuous  application  from  under- 
nourished children. 

That  this  long  school  program  is  not  neces- 
sary for  all  children  is  proved  by  the  fact  that 
many  of  the  children  in  our  nutrition  classes  are 
able  to  keep  up  with  their  grade  when  excused 
at  the  middle  of  the  morning  session.  The 
daughter  of  a  physician  was  taken  out  of  school 
entirely,  but  was  able  to  make  the  same  progress 
as  her  class  upon  an  hour's  tutoring  a  day. 
This  subject  of  the  school  program  is  of  so 
much  importance  that  it  will  be  separately  dis- 
cussed in  Chapter  XXII. 

Outside  Studies  and  Clubs. — During  the  late 
war  many  schools  kept  the  children  after  hours 
for  knitting,  sewing,  and  other  patriotic  work. 
The  fact  that  attendance  was  not  compulsory 
did  not  remove  the  pressure  of  the  suggestion 
that  it  would  be  selfish  or  unpatriotic  to  with- 
draw. 

Even  religion  may  be  the  occasion  for  check- 
ing growth.  Long  church  services,  Sunday 
school,  choir  rehearsals,  revivals,  and  other  re- 

87 


NUTRITION  AND  GROWTH  IN  CHILDREN 

ligious  observances  impose  a  greater  strain  than 
the  malnourished  child  is  able  to  bear.  Among 
the  Hebrews,  children  are  expected  to  spend 
from  four  to  eight  hours  each  week  studying 
Biblical  history  and  the  Hebrew  language,  and 
these  classes  are  often  held  in  badly  ventilated 
and  poorly  lighted  rooms. 

Music  lessons  and  dancing  classes  are  other 
sources  of  strain  and  fatigue  that  should  be 
omitted  during  the  period  of  treatment. 

The  child's  program  is  further  complicated 
by  the  numerous  clubs  organized  for  his  wel- 
fare or  improvement.  Each  of  these,  however 
commendable  in  itself,  takes  its  toll  of  strength 
and  energy,  especially  from  the  child  who  is 
always  stimulated  to  do  his  best  and  to  keep  up 
with  his  fellows  in  any  undertaking.  A  little 
girl  of  ten  in  one  of  our  nutrition  classes  was 
found  to  be  connected  with  11  of  these  organiza- 
tions, and  the  price  paid  in  one  week  was  lit- 
erally a  pound  of  flesh ! 


CHAPTER  X 


MEASURED  FEEDING 


The  feeding  of  infants  has  become  so  thor- 
oughly standardized  that  the  amount  of  milk 
and  other  foods  required  is  now  prescribed  with 
great  exactness.  In  the  case  of  older  children 
this  precision  does  not  obtain,  and  the  feeding 
of  children  above  the  age  of  two  is  still  largely 
a  matter  of  guesswork  or  caprice.  This  care- 
less feeding  of  the  older  child  is  responsible  for 
many  of  the  serious  diseases  of  early  life,  and 
especially  for  many  disturbances  of  the  ner- 
vous system,  which  are  difficult  to  remedy.  It 
is  one  of  the  most  common  causes  of  malnu- 
trition. 

Some  one  has  well  asked,  ''Wliy  do  physi- 
cians exercise  so  much  care  in  prescribing  drugs 
that  are  administered  only  occasionally,  and  so 
little  care  in  prescribing  food  which  is  taken 
daily?" 

To  overcome  this  haphazard  method  of  feed- 
ing something  more  than  the  general  advice 
usually  given  is  necessary.  It  is  true  that  the 
child  should  have  "good,  nourishing  food  and 

89 


NUTRITION  AND  GROWTH  IN  CHILDREN 

plenty  of  it";  and  that  he  should  not  take 
^'  anything  indigestible."  But  the  fact  remains 
that  every  growing  child  needs  a  certain  total 
amount  of  food  daily  to  supply  him  with  the 
energy  required  for  his  normal  activities  and 
growth,  and  the  only  way  to  determine  whether 
he  is  taking  this  amount  is  by  a  careful  method 
of  measured  feeding. 

Food  Values. — For  the  proper  feeding  of  the 
child  both  parent  and  physician  should  have  an 
adequate  knowledge  of  food  values,  covering  at 
least  the  principal  items  of  food  in  common  use. 
Three  methods  for  determining  food  values  are 
available.  One  in  portions  of  100  grams  with  a 
table  of  equivalent  caloric  values;  a  second, 
taking  as  a  unit  the  ordinary  serving;  and  a 
third,  in  portions  of  100  calories,  with  an  equiv- 
alent table  of  weight  by  ounces.  As  food  is 
bought  by  the  ounce  or  pound,  the  first  method 
requires  a  mental  readjustment,  which  makes 
it  difficult  of  adoption  by  most  persons  con- 
cerned with  the  diet  of  children.  All  infant 
feeding  in  this  country  is  by  ounces,  and  change 
to  another  standard  of  measurements  is  im- 
practical except  for  laboratory  work.  The  sec- 
ond method  is  unreliable  because  what  is  an  or- 
dinary serving  for  one  person  is  a  very  different 
quantity  for  another. 

90 


MEASURED  FEEDING 

In  our  nutrition  clinics  we  have  therefore 
adopted  the  third  method,  which  is  that  pro- 
posed by  Irving  Fisher  in  1906,  and  is  called  the 
calory  per  cent  method.  Professor  Fisher's 
tables  indicate  the  amount  of  each  kind  of  food 
necessary  to  furnish  100  calories  of  food  value, 
and  these  amounts  are  used  as  standard  por- 
tions. For  example,  one  slice  of  bread  has  a 
value  of  100  calories ;  also,  one  pat  of  butter,  the 
lean  meat  in  an  ordinary  lamb  chop,  one  slice 
of  bacon,  or  five  ounces  of  milk.  A  table  cover- 
ing the  principal  items  of  food  in  100  calory 
portions,  with  the  proportion  of  proteid,  fat, 
and  carbohydrate,  will  be  found  at  the  end  of 
this  chapter. 

These  units  or  multiples  of  units  can  readily 
be  made  the  basis  for  the  serving  of  food,  and 
an  accurate  record  can  be  kept  without  diffi- 
culty. Liquid  measure  is  convertible  into 
ounces  on  the  basis  of  eight  ounces  to  the  glass 
and  one-half  ounce  to  the  tablespoonful,  and 
the  rough  measure  by  size,  tablespoonful,  etc., 
can  be  verified  by  finding  on  postal  scales  the 
actual  weight  of  the  portion  served.  "Where  the 
exact  measure  of  proteid,  fat,  or  carbohydrate 
is  desired,  as  in  cases  of  nephritis,  jaundice,  or 
diabetes,  the  total  number  of  calories  of  proteid 
or  carbohydrate  may  be  divided  by  four,  and 

91 


NUTRITION  AND  GROWTH  IN  CHILDREN 

the  total  amount  of  fat  by  nine,  to  give  the 
equivalent  value  in  grams. 

One  of  the  great  advantages  of  this  method 
of  measured  feeding  is  that  it  gives  a  basis  for 
visual  comparison  of  food  values,  and  a  knowl- 
edge of  the  caloric  value  of  the  foods  that  it 
is  necessary  to  consider  in  a  given  case  can  be 
acquired  in  a  comparatively  short  time. 

A  Food  Exhibit. — A  food  exhibit  arranged 
in  100  calory  portions  will  help  to  fix  relative 
values  in  the  memory.^  Figure  17  shows  such 
an  exhibit,  from  which  it  will  be  seen  that  such 
inexpensive  foods  as  cereals  are  high  in  food 
value,  and  that  it  takes  a  quart  of  thin  soup  to 
equal  in  value  a  pat  of  butter,  an  egg,  or  five 
ounces  of  milk. 

A  Diet  Record. — The  food  habits  of  children 
are  so  constant  that  a  record  of  the  food  taken 
during  two  consecutive  days  each  week  is  a  suffi- 
ciently accurate  indication  of  the  child's  cus- 
tomary diet.  If  he  eats  less  on  one  day,  he  will 
make  it  up  the  next,  and  vice  versa.  We  there- 
fore require  from  each  child  a  48-hour  record 
of  all  food  taken,  measured  according  to  the 
directions  given,  and  the  average  of  these  two 

^  Excellent  food  models  can  be  obtained  from  The  Plastic 
Art  and  Novelty  Company,  1495  Thiid  Avenue,  New  York 
City. 

92 


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MEASURED  FEEDING 

days  represents  the  habitual  daily  intake  of 
food. 

In  the  application  of  this  method  it  is  im- 
portant to  secure  the  first  record  before  making 
any  suggestions  as  to  change  in  diet,  in  order  to 
learn  the  patient's  previous  habits.  This  pre- 
liminary record  will  show,  not  only  the  kind 
of  food  indulged  in,  but  how  much  is  habitually 
taken,  and,  more  important  still,  the  likes  and 
dislikes  of  the  child.  It  is  always  well  to  defer 
to  taste  as  much  as  possible,  retaining  in  the 
diet  such  wholesome  foods  as  are  agreeable  to 
the  child  and  making  the  necessary  adjust- 
ment by  substituting  other  foods  for  those  that 
should  not  be  taken. 

The  preliminary  list  is  often  the  first  relia- 
ble knowledge  obtained  by  parent  or  physician 
on  which  to  base  an  attack  on  the  fundamental 
cause  of  the  child's  malnutrition.  Mistaken 
ideas  as  to  food  values  are  also  revealed  by  this 
method,  with  its  record  in  plain  figures.  A  girl 
of  14  came  under  my  care  because  she  was  un- 
dersized and  delicate.  For  years  she  had  taken 
daily  a  large  serving  of  clear  soup,  the  stock 
of  which  was  made  from  the  most  expensive 
cuts  of  meat,  which  her  father  thought  especially 
nutritious,  not  knowing  that  it  requires  nearly 
a  quart  to  equal  the  value  of  a  pat  of  butter. 

93 


NUTRITION  AND  GROWTH  IN  CHILDREN 

After  taking  this  soup  she  ate  very  little  else  at 
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FiGUBE   18.      INSUFFICIENT  FOOD — THIN   SOUP 

LilUan  was  in  the  habit  of  taking  a  large  bowl  of  thin  soup  at  the 
beginning  of  her  dinner.  This  spoiled  her  appetite  for  the  rest  of 
the  meal,  and  her  diet  list  averaged  only  about  1,100  calories. 
When  the  soup  was  omitted,  she  ate  more  nourishing  foods,  and 
her  chart  shows  an  immediate  and  rapid  gain  in  weight. 


value  of  her  24-hour  ration  by  an  appreciable 
amount.  This  effect  was  not  apparent  to  either 
parent  or  physician  until  the  total  amount  of 
food   was   measured.    By   omitting   the    soup 

94 


MEASURED  FEEDING 

other  foods  of  higher  caloric  value  were  nat- 
urally substituted,  and  the  child  at  once  began 
to  gain.  Two  years  later  she  returned  for 
treatment  because  of  overweight. 

It  is  surprising  what  gross  errors  are  made 
in  diet  until  one  is  faced  with  the  exact  list  of 
what  is  eaten.  One  mother  remarked  of  her 
son's  list:  ''John  calls  this  his  diet  list;  I  call 
it  his  confession." 

How  to  Make  Changes  in  the  Diet. — Having 
obtained  from  the  48-hour  record  a  knowledge 
of  the  kind  and  quantity  of  food  taken,  it  is  an 
easy  matter  to  increase  or  decrease  the  24-hour 
total  by  simple  changes.  For  example,  in  the 
diet  list  of  a  nine-year-old  child  in  one  of  our 
classes  a  very  inadequate  breakfast  was  re- 
corded, which,  by  simple  changes,  was  doubled 
in  value. 


BREAKFAST  I 

Calories 

Cream  of  wheat 

4  tablespoonfuls 

100 

Sugar 

2  teaspoonfuls 

50 

Egg  (soft  boiled) 

One 

100 

Roll 

One 

100 

Butter 

Half -pat 

50 

Tea  (milk  and  sugar) 

1  cup 

50 

Total  calories 

450 

95 


NUTRITION  AND  GROWTH  IN  CHILDREN 


BREAKTAST  n 

Calories 

Cream  of  wheat 

4  tablespoonfuls 

100 

Cream  (16%) 

3  ounces 

150 

Sugar 

2  teaspoonfuls 

50 

Egg  (scrambled — 1  egg, 

1  ounce  cream,  V2  pat 

butter) 

200 

Toast 

1  slice 

100 

Butter 

1  pat 

100 

Cocoa 

6V2  ounces 

200 

Total  calories 

900 

By  taking  cream  with  the  cereal,  and  scram- 
bling the  eggs  with  cream  and  butter,  250  calo- 
ries were  added  to  Breakfast  I.  By  substitut- 
ing cocoa  for  the  tea,  and  taking  a  whole  pat 
of  butter  with  the  toast  200  calories  more  were 
added,  thus  doubling  the  value  of  the  meal. 
These  changes  were  made  without  conflicting 
with  the  child's  taste  and  without  upsetting  the 
home  menu. 

Such  changes  do  not  force  the  child  to  take 
too  much  food  at  one  time,  and  there  is,  there- 
fore, little  danger  of  causing  indigestion.  The 
undernourished  child  is  like  a  person  conval- 
escing from  a  severe  illness,  requiring  two  or 
even  three  times  as  much  food  as  is  needed 

96 


MEASURED  FEEDING 

when  he  is  in  normal  condition.  Children  who 
are  underweight  seem  to  have  a  remarkable 
ability  to  digest  food,  while  on  the  other  hand, 
in  the  case  of  those  who  are  overweight,  symp- 
toms of  indigestion  disappear  with  a  diminu- 
tion of  the  day's  ration. 

An  Aid  to  Diagnosis. — Undernourished  chil- 
dren almost  invariably  take  too  little  food,  and 
underfed  children  all  show  signs  of  malnutri- 
tion. If  a  prompt  advance  in  weight  does  not 
follow  increased  feeding,  it  is  probable  that 
some  organic  disturbance, or  other  unfavorable 
condition  is  the  obstacle  to  progress.  Measured 
feeding  is  therefore  a  valuable  aid  in  medical 
diagnosis. 

It  is  a  futile  but  common  expedient  to  give 
children  tonics,  transport  them  to  different  cli- 
mates, and  subject  them  to  all  kinds  of  treat- 
ment, in  order  to  cause  a  gain  in  weight,  when 
a  record  of  their  diet  often  shows  that  they  are 
taking  not  more  .than  1,000  calories  per  day. 
This  amoTJ^it  represents  the  food  requirements 
of  a  healthy  infant,  and  could  not  provide  for 
gain  in  an  older  child  unless  he  were  actually 
confined  to  bed. 

Increasing  the  24-Hour  Amount. — During  the 
time  the  child  is  under  treatment  th^  amount  of 

97 


NUTRITION  AND  GROWTH  IN  CHILDREN 

food  can  be  increased  most  easily  by  adding 
mid-morning  and  mid-afternoon  lunches  to  his 
usual  three  meals  a  day.  He  will  assimilate 
more  food  in  five  light  meals  than  in  three 
heavier  ones.  These  lunches  should  consist  of 
easily  digested  food  that  will  not  destroy  the 
appetite  for  the  next  meal.  Sandwiches,  bread 
and  milk,  or  oatmeal  crackers  with  fruit  are 
suitable  and  satisfying.  Sweets  should  be 
avoided  unless  in  the  form  of  prunes,  figs,  or 
dates.  These  extra  feedings  should  have  a 
value  of  200  to  400  calories,  and  should  be  as 
regularly  timed  as  the  principal  meals. 

The  Amount  of  Food  Needed. — The  follow- 
ing table  shows  the  approximate  caloric  re- 
quirements for  a  child  of  normal  weight.  The 
growing  child's  need  is  relatively  greater  than 
that  of  the  normal  adult,  because  of  his  in- 
creased activities  and  growth.  For  a  malnour- 
ished child  of  six  to  14  years  of  age,  who  is 
seven  or  more  per  cent  under  weight  for  height 
and  continuing  his  usual  activities,  between 
2,000  and  3,000  calories  per  day  are  necessary 
for  proper  gain,  but  such  children  frequently 
take  as  much  as  5,000  calories  daily.  The 
amount  of  food  needed  is  measured  by  the 
growth  to  be  accomplished  and  the  energy  to  be 
spent  in  work  and  in  play. 

98 


MEASURED  FEEDING 
Table  II. — Approximate  Calobic  Requirements  in  Health 


Age 

Calories  per  pound 

Total   Calories  In 
24   hours 

1 

40-50 

330-  950 

2 

40-45 

900-1100 

3 

38-43 

1100-1300 

4 

35-40 

1300-1400 

5 

34-39 

1400-1500 

6 

32-38 

1500-1000 

7 

32-38 

1600-1700 

8 

32-38 

ITOOI'IOO 

9 

32-38 

1900-2100 

10 

33-38 

2100-2300 

11 

33-38 

2300-2500 

12 

33-38 

2700-2900 

13 

33-38 

2900-3200 

14 

32-38 

3200-3400 

15 

28-38 

3300-3900 

16 

26-36 

3200-4100 

17 

24-33 

3100-3900 

18 

23-30 

3000-3700 

Adult  * 

18-24 

2000-3300 

♦  Male  150  pounds.     Female  130  pounds. 

The  large  range  in  the  number  of  calories  is 
required  on  account  of  differences  in  activity, 
power  of  assimilation,  and  rate  of  growth.  At 
any  given  age  the  greater  the  weight  the  smaller 
the  number  of  calories  needed.  Therefore  the 
smaller  number  of  calories  in  the  table  should 
be  the  guide  for  heavier  children  and  the  maxi- 
mum the  standard  for  children  of  lower  weight.^ 

Every  child  requires  sufficient  calories  to 
keep  his  weight  at  the  point  that  is  normal  for 
him,  and  this  is  usually  the  weight  at  which 
he  feels  best.     The  48-hour  record  should  be 


2  See  table  of  average  weights  for  given  heights  in  Ap- 
pendix I,  p.  305. 

99 


NUTRITION  AND  GROWTH  IN  CHILDREN 

kept,  and  the  patient  weighed  once  a  week,  until 
his  food  requirements  are  known.  The  normal 
child  can  then  be  made  to  gain,  lose,  or  remain 
stationary  in  weight  as  desired. 


Table  III.    Quantities   of  Food  Necessaby  to  Yield   100 

Caloeies,  with  the  Proportion  of  Peoteid,  Fat 

AND  Carbohydrate  * 


ts  =  teaspoonful 

tbsp  = 

tablespoonful 

h  =  heaping 

aver  = 

average 

sq  =  square 

quar  = 

quarter 

Fish 

and  Meat 

Calories 

Oz. 

P.  F.  Ch. 

Cod,  boiled 

9 
SI   a> 

r  3.6 

90-10-0 

Haddock,  broiled 

•sg' 

3.3 

90-10-0 

Bluefish,  broiled 

III' 

2.4 

71-29-0 

Halibut,  broiled 

©  n 

-3. 

61-39-0 

Mackerel,  broiled 

CO 

r  2.6 

56-44-0 

Salmon,  canned 

(C 

O 

1.8 

45-55-0 

Roast  veal 

•s 

2.7 

71-29-0 

Eoast  chicken 

0^ 

1.9 

73-23-4 

Dried  beef 

.2  ' 

1.7 

67-33-0 

Boiled  mutton 

'3 
II 

2.1 

74-26-0 

Round  steak,  broiled 

1.9 

48-52-0 

Roast  pork 

O 

1.7 

55-45-0 

Tripe 

ei 

2.4 

46-54-0 

Roast  lamb 

.  1.8 

41-59-0 

Tenderloin  steak 

§* 

'  1.3 

34-66-0 

Roast  mutton 

Q 

1.1 

33-67-0 

Ham,  boiled 

i> 

1.2 

29-71-0 

Corned  beef,  boiled 

l-H 

1.2 

21-79-0 

Tongue 

'3 

1.2 

27-73-0 

Roast  beef 

1.2 

46-54-0 

Lamb  chop 

II 

1. 

40-60-0 

Roast  turkey 

s 

1. 

40-60-0 

Roast  duck 

-I 

1. 

30-70-0 

*  These  analyses  are  based  for  the  greater  part  upon  Bulletin  28, 
Office  of  Experiment  Stations,  U.  S.  Department  of  Agriculture. 
The  values  of  cooked  foods  are  necessarily  approximate  and  allow- 
ance should  be  made  for  dressings,  sauces,  etc.,  especially  the  fat 
in  which  foods  are  cooked. 

100 


MEASURED  FEEDING 


Table  III.    Quaktities  of  Food  Necessabt  to  Yield  100 

Calobies,  with  the  Pboportion  of  Proteid,  Fat 

AND  Cabbohydbate — Continued 


Fish  Wild  Meat 

Calories 

Oz. 

P.  F.  Ch. 

Sausage 

two-thirds 

.7 

20-78-2 

Bacon 

1  slice 

.5 

13-87-0 

Salt  pork 

1  in  sq 

.5 

4-96-0 

Clams 

12  to  16 

4.7 

56-8-36 

Oysters 

twelve 

7. 

49-22-29 

Sardines 

four 

1.3 

34-66-0 

Lobster 

3  h  tbsp 

4.1 

78-20-2 

Scallops 

2  h  tbsp 

2.5 

80-1-19 

Lean  part  lamb 

chop  weighs  1 

oz. 

Fish  and  meat 

vary  in  value  according 
Dairy  Products 

to  fat 

present. 

Butter 

1  pat 

.4 

1-99-0 

Cheese: 

American 

1  cu  in 

.9 

25-73-2 

Cottage 

2  h  tbsp 

.1 

76-8-16 

Cream,  full 

1  cu  in 

.9 

25-73-2 

Neufchatel 

1  cu  in 

.9 

22-76-2 

Pineapple 

1  cu  in 

.9 

25-73-2 

Eoquefort 

1  cu  in 

.9 

25-73-2 

Swiss 

1  cu  in 

Soups 

.9 

25-74-1 

Cream : 

Asparagus 

[3.9 

12-70-18 

Celery 

N 

3.8 

10-73-17 

Corn 

,_  o 

3.2 

12-43-45 

Pea 

^M] 

3.2 

16-48-36 

Tomato 

3.5 

10-70-20 

Clam  chowder 

o 

3.8 

20-38-42 

Fish  chowder 

3.9 

34-35-31 

Thick: 

Bean 

N] 

f  5.4 

20-20-60 

Chicken 

1— •  o 

6. 

72-12-16 

Split  pea 
Meat  stew 

6. 
4.3 

26-2-72 
23-49-28 

Oyster  stew 

Q 

5. 

23-57-20 

Clear: 

N 

Bouillon 

-  °  r 

32. 

84-8-8 

Consomme 

29. 

85-0-15 

Vegetable 

101 

^          1 

25. 

85-0-15 

NUTRITION  AND  GROWTH  IN  CHILDREN 

Table  III.     Quantities   of  Food  Necessaby  to  Yield   100 

Caloeies,  with  the  Pbopoetion  of  Pboteid,  Fat 

and  Carbohydrate — Continued 


Asparagus : 

Fresh 

Cooked 
Beans : 

Baked 

Lima,  fresh 

String 
Beets 
Cabbage 
Carrots 
Cauliflower 
Celery 
Corn : 

Canned 

Green 
Cucumber 
Lettuce 
Mushrooms 
Onions 
Parsnips 
Peas: 

Green 

Canned 
Potatoes : 

Sweet,  baked 

White,  baked 
Rhubarb : 

Stewed 
Spinach,  boiled 
Squash 
Succotash 
Tomatoes : 

Canned 

Fresh 
Turnips 


Corn  flaJifi* 
Cr©am  of  wheat 
Farina 
Grape  nuts 
Hominy 
Indian  meal 


Calories 

Oz. 

P.  F.  Ch. 

20  stalks 

15.9 

32-8-60 

7  h  tbsp 

7. 

34-6-60 

1  tbap 

2.7 

21-18-61 

2  tbsp 

4.4 

21-4-75 

10  tbsp 

8.5 

22-7-71 

6  h  tbsp 

7.7 

14-2-84 

60  h  tbsp 

11. 

20-8-72 

4  h  tbsp 

5.S 

10-5-85 

24  h  tbsp 

11.5 

23-15-62 

1  bunch 

19. 

24-5-7L 

2  h  tbsp 

3.5 

11-11-78 

2  ears 

3.5 

13-10-77 

2  large 

20. 

18-10-72 

2  large  heads 

18. 

25-14-61 

8  large 

7.6 

31-8-61 

4  h  tbsp 

7.2 

13-6-81 

5  h  tbsp 

5.8 

10-7-83 

4  h  tbsp 

3.5 

28-4-68 

4  h  tbsp 

4.4 

25-3-72 

%  aver 

1.5 

6-9-85 

1  aver 

3.6 

11-1-88 

2  h  tbsp 

1.7 

1-2-97 

4  h  tbsp 

21. 

12-8-80 

4  h  tbsp 

7.4 

12-5-83 

3  h  tbsp 

3.5 

15-9-76 

12  h  tbsp 

15.6 

21-8-71 

4  aver 

15.5 

16-16-68 

6  h  tbsp 

8.7 

13-4-83 

Cereals 

10  h  tbsp 

1. 

6-4-90 

4  h  tbsp 

6. 

12-3-86 

4  h  tbsp 

6. 

12-4-84 

2  h  tbsp 

1. 

13-2-85 

S  h  tbsp 

4.2 

11-2-87 

3  h  tbsp 

6. 

10-5-85 

102 


MEASURED  FEEDING 


Table  III.     Quantities   of  Food  Necessabt  to  Yield   100 

Calories,  with  the  Proportion  of  Proteid,  Fat 

AND  Carbohydrate — Continued 

Cereals 


Calories 

Macaroni : 

Oz. 

P.  F.  Ch. 

Boiled 

4  h  tbsp 

4. 

15-2-83 

Oatmeal 

4  h  tbsp 

5.6 

17-16-67 

Puffed  rice 

10  h  tbsp 

1. 

9-1-90 

Piice,  boiled 

4  h  tbsp 

3.1 

10-1-89 

Shredded  wheat 

cne 
Bread 

.9 

13-5-82 

White 

3x3%xl  in 

1.3 

14-6-80 

Whole  wheat 

2y2x2%xy2  in 

1.4 

16-3-81 

Corn 

2x2x1  in 

1.2 

10-24-66 

Biscuit 

one 

1.3 

11-27-62 

Poll,  Vienna 

one 

1.3 

12-7-81 

Zwieback 

3  pieces 

.8 

9-21-70 

Pilot 

%  cracker 
Crackers 

.9 

11-12-77 

Boston 

one 

.9 

11-19-70 

Educator 

twelve 

1. 

40-3-57 

Graham 

two 

.8 

9-20-71 

Oatmeal 

seven 

.8 

11-24-65 

Oyster 

twenty-four 

.8 

7-24-69 

Saltines 

six 

.8 

10-26-64 

Uneedas 

four 
Fruits  (fresh) 

.9 

9-20-71 

Apple 

1  large 

7.3 

3-7-90 

Banana 

1  large 

5.5 

5-5-90 

Blackberries 

4  h  tbsp 

6.1 

9-16-75 

Canteloupe 

one-half 

8.6 

6-0-94 

Grapefruit 

one-half 

11.4 

3-12-85 

Grapes,  Concord 

1  bunch 

4.8 

5-15-80 

Lemon 

1  large 

7.6 

9-14-77 

Orange 

1  large 

9.4 

7-2-91 

Peach 

3  aver 

10.5 

6-3-91 

Pear 

1  large 

6.3 

4-7-89 

Pineapple 

2  slices 

8.2 

4-6-90 

Raspberries 

9  h  tbsp 

5.3 

10-14-76 

Strawberries 

10  h  tbsp 

9. 

10-15-75 

Watermelon 

11.7 

5-6-89 

103 


NUTRITION  AND  GROWTH  IN  CHILDREN 


Table  III.    Quantities  of  Food  Necessaby  to  Yield   100 

Calobies,  with  the  Pboportion  of  Pboteid,  Fat 

AND  Cabbohydeate — Continued 

Fruits  (dried),  edible  portion 


Calories 

Oz. 

P.  F.  Ch. 

Dates 

3  large 

1. 

2-7-91 

Figs 

1  large 

1.1 

5-0-95 

Prunes 

3  large 

1.4 

3-0-97 

Kaisins 

10  large 
Desserts 

1.1 

3-9-88 

Cakes : 

Sponge 

2x2x1  in 

.9 

11-19-70 

Chocolate  layer 

2x11/2x1  in 

1. 

7-22-71 

Frosted 

2xiyoxl  in 

1. 

6-22-72 

Gingerbread 

2x2x1  in 

1.2 

8-22-70 

Lady  fingers 

two 

.9 

10-12-78 

Macaroons 

two 

.8 

6-33-61 

Cookies 

two 

.8 

7-22-71 

Chocolate  Eclair 

1/^  small 

.8 

4-33-63 

Doughnut 

2/3 

.8 

6-45-49 

Pies: 

Custard 

1/5  of  a  quar 

1.9 

9-32-59 

Lemon 

1/5  of  a  quar 

1.4 

6-36-58 

Squash 

1/5  of  a  quar 

1.9 

10-25-65 

Apple 

1/6  of  a  quar 

1.6 

3-41-56 

Mince 

1/6  of  a  quar 

1.2 

8-38-54 

Puddings: 

Bread 

1  h  tbsp 

1.6 

10-20-70 

Baked  custard 

2  h  tbsp 

2.6 

17-37-46 

Rice  custard 

2  h  tbsp 

2.7 

8-13-79 

Apple  tapioca 

2  h  tbsp 

3. 

H-98 

Indian 

1  h  tbsp 

2. 

12-25-63 

Ice  Cream 

1  h  tbsp 
Sioeets 

2. 

6-55-39 

Cocoa 

4  h  ts 

.7 

17-53-30 

Chocolate 

1/2  sq 

.56 

8-72-20 

Fruit  sauces 

2  tbsp 

2. 

1-3-96 

Jellies,  all 

1  tbsp 

1. 

1-0-99 

Marmalade 

1  tbsp 

1. 

1-2-97 

Honey 

1  tbsp 

1. 

1-0-99 

Sugar : 

Granulated 

4  ts 

.9 

0-0-100 

Powdered 

4  h  ts 

.9 

0-0-100 

Cube 

4  lumps 

.9 

0-0-100 

Domino 

6  small  or 

3  large 

.9 

0-0-100 

Maple 

4  ts 

1. 

1-0-99 

Maple  Syrup 

1  tbsp 
104 

1.2 

0-0-100 

MEASURED  FEEDING 


Table  III.     Quantities   of  Food  Necessary  to  Yield   100 

Calories,  with  the  Proportion  of  Proteid,  Fat 

AND  Carbohydrate — Continued 


Nuts 


Calories 

Oz. 

P.  F.  Ch. 

Almonds 

eight 

.5 

13-77-10 

Brazil 

three 

.5 

10-86-4 

Chestnuts,  Italian 

seven 

1.5 

10-20-70 

Filberts 

ten 

.5 

9-84-7 

Peanuts 

1?>  double 

.6 

20-63-17 

Pecans 

eight 

.5 

6-87-7 

Walnuts,  English 

ten 
Miscellaneous 

.5 

10-83-7 

Olives,  green 

seven 

1.6 

1-84-15 

Alcohol 

.5 

Foods  Used  for  Infants  and  in  Illness 


Albumin  water 

1  white  to  8  oz 
Barley  Water 

1  oz  to  qt 
(.13     .07     2.44) 

Barley  gruel 

2  oz  to  qt 
(.27     .15     4.89) 

Rolled  oats  water 

1  oz  to  qt 
(.26     .14     1.67) 

Rolled  oats  gruol 

2  oz  to  qt 
(.52     .28     3.34) 

Beef  broth 
Chicken  broth 
Beef  juice: 

Cold  process 

Warm  process 
Orange  juice 
Olive  oil 
Malt  soup  (Keller's) 

(12     1.2     12.1) 
ITuman  milk 

(1.25     3.5     7.0) 


Cal.  tooz. 

Oz. 

Calories 
P.  F.  Ch. 

3.5 

28. 

100-0-0 

3.1 

32. 

4-6-90 

6.2 

16. 

4-6-90 

2.5 

40. 

12-14-74 

5. 

1.1 

1. 

20. 

88. 

100. 

12-14-74 

100-0-0 

30-55-15 

14. 

19. 

14. 

25iO. 

7. 
5.3 
7. 
.4 

100-0-0 
78-22-0 
0-0-100 
0-100-0 

) 

20. 

6. 

12-16-72 

20. 

5. 

8-52-40 

105 


NUTRITION  AND  GROWTH  IN  CHILDREN 


Table  III.     Quantities   of   Food  Necessary  to 
Calobies,  with  the  Propobtion  of  Proteid, 
AND  Carbohydbate — Continued 
Foods  Used  for  Infants  and  in  Illness 


Oz. 
5. 


Cow's  milk                  Cal.  to  oz. 

(3.5     4.0     4.5) 

20. 

Pvich  milk 

(3.5     5.0     4.5) 

22. 

Cream : 

Top  milk,  407o 

( 2.2     40     3 ) 

100. 

Top  milk,  16% 

(3.25     1()     4.05) 

50. 

Top  milk,  7% 

(3.5     7     4.5) 

27. 

Skimmed  milk 

(3.6     1.8     4.5) 

14. 

Butter  milk 

(3.6     .5     4.06) 

11. 

Condensed  milk  (Eagle 

brand ) 

(8.43    6.04    50.69)100. 

Six  parts  water 

(1.20     .99     7.23) 

13. 

Nine  parts  water 

(.84     .69     5.1) 

9.5 

Whey 

From  whole  milk 

( .94     .96     5.49 ) 

10.5 

Eiweismilch 

(13-25-15) 

12. 

Koumyss : 

From  cow's  milk 

(2.66     1.83     4.09)      12.5 
Sugar,  gran  4  ts: 

Powdered,  4  h  ts 
Milk  sugar 
Dextri  maltos,  3  h  ts 
Mellen's  food,  3  h  ts 
Malted  milk,  3  h  ts 
Wheat  or  barley  flour 
Apple  sauce,  2  tbsp 
Prune  sauce,  3  med  w  juice 
Scraped  beef 
Egg,  one  large: 

t\Tiite,  seven 

Yolk,  two 
Zwieback,  three 


4.5 


Yield   100 
Fat 


Calories 
P.  F.  Cli. 
20-52-28 

18-59-23 


1. 

2-95-3 

2. 

7-84-9 

3.75 

15-66-19 

7. 

30-33-37 

9. 

41-13-46 

1. 

11-20-69 

7.5 

11-20-69 

[0.75 

11-20-69 

9.5 

11-25-64 

8.5 

30-56-14 

8. 

24-38-38 

.86 

0-0-100 

.86 

0-0-100 

.9 

0-0-100 

.9 

0-0-100 

.9 

12-6-82 

.83 

15-19-66 

1. 

12-3-85 

2.2 

1-4-95 

3.8 

2-1-97 

2. 

61-39-0 

2.1 

36-64-0 

6.4 

97-3-0 

.94 

17-83-0 

.8 

9-21-70 

106 


CHAPTER  XI 

DIET   AND   FOOD    HABITS 

It  is  universally  recognized  that  diet  is  an 
important  factor  in  nutrition.  What  is  not  suf- 
ficiently recognized  is  that  other  factors  of 
equal  importance  must  be  controlled  before  mal- 
nutrition can  be  removed  and  proper  growth 
established.  Attention  must  be  given,  not  only 
to  the  character  of  the  foods  selected,  but  also 
to  the  fuel  value  of  the  amount  taken,  and  to 
the  child's  habits  of  eating. 

The  problem  of  an  '^optimum"  or  ideal  diet 
is  receiving  the  attention  of  the  chemist,  the 
biologist,  and  the  anatomist,  but  it  has  not  yet 
been  discovered  just  what  amount  of  each  food 
element  is  needed  by  the  growing  child.  This 
is  especially  true  of  the  vitamins,  and  even 
were  it  known  how  much  of  these  is  needed,  it 
would  still  be  necessary  to  determine  under 
what  conditions  they  are  best  absorbed.  Few 
investigations,  other  than  clinical  research, 
have  yet  been  made  to  determine  the  influence 
of  physical  defects,  fatigue,  and  toxins  on  ab- 
sorption.    Emotional  reactions,  such  as  fear, 

107 


NUTRITION  AND  GROWTH  IN  CHILDREN 

anger,  hurry,  worry,  and  stress  must  also  be 
taken  into  account  as  affecting  the  child's  power 
of  assimilation. 

If  the  body  is  not  in  these  respects  in  a  con- 
dition favorable  for  absorption,  the  diet  may  be 
an  "optimum"  one,  the  amount  taken  double  or 
treble  that  necessary  for  growth,  yet  the  child's 
weight  will  remain  stationary,  or  may  even  de- 
crease, for  weeks  and  months  at  a  time. 

Recent  investigations  have  demonstrated  the 
harmful  effect  of  the  too  exclusive  use  of  de- 
germinated  foods  such  as  milled  flour,  polished 
rice,  and  artificially  prepared  products  in  caus- 
ing a  deficiency  of  valuable  constituents.  New 
evidence  of  this  kind  must  not  be  neglected,  but 
there  is  no  cause  for  alarm  except  where  good 
milk  cannot  be  obtained  in  sufficient  quantity  to 
supply  the  deficiency.  Our  present  knowledge 
indicates  that  if  a  child  takes  a  sufficient  amount 
of  the  usual  foods  of  the  average  American  ta- 
ble, including  a  pint  of  milk  a  day,  he  will  have 
all  the  dietary  essentials  for  proper  growth. 
It  is  a  safe  rule  to  require  the  child  to  take  a 
little  of  each  food  provided  for  the  family  table 
in  order  that  he  may  not  get  the  idea  that  he 
cannot  eat  this  or  that,  and  thus  be  deprived  of 
an  essential  food  element. 

The  48-hour  record  that  is  used  to  check  the 
108 


DIET  AND  FOOD  HABITS 

total  amount  of  food  taken  is  also  the  best 
guide  to  possible  food  deficiencies  and  to  faulty 
food  habits.  In  checking  and  correcting  many- 
thousands  of  diet  lists  we  have  found  the  chief 
errors  to  be: 

1.  The  omission  of  cereals  and  milk 

2.  The  use  of  tea  and  coffee 

3.  The  taking  of  sweets  between  meals 

4.  Irregular  meals,  and  irregular  amounts  at  the 
different  meals 

5.  Insufficient  24-hour  amount  of  food 

The  Balanced  Diet. — It  is  not  necessary  to 
provide  an  unusual  or  peculiar  diet  for  the  mal- 
nourished child.  Elaborate  dishes  and  delica- 
cies intended  to  tempt  the  appetite  are  of  less 
value  than  plain  wholesome  food  in  proper 
amounts.  Catering  to  childish  whims  is  one  of 
the  chief  causes  of  the  surprisingly  large  per- 
centage of  malnutrition  found  among  the  chil- 
dren of  the  rich.  The  child  should  be  allowed 
to  experience  the  healthy  satisfaction  of  clear- 
ing his  plate  and  asking  for  more.  Experience 
shows,  fortunately,  that  children  thrive  on  sim- 
ple and  comparatively  inexpensive  foods — milk 
and  milk  products,  whole  cereals,  corn,  rye,  and 
whole  wheat  bread,  fish  and  the  cheaper  cuts 
of  meat,  such  vegetables  as  potatoes,  onions, 

109 


NUTRITION  AND  GROWTH  IN  CHILDREN 

carrots,  and  greens,  and  fruits  and  berries  as 
they  are  available. 

In  normal  health  the  question  of  a  balanced 
diet,  or  the  proper  proportion  of  proteid,  fat, 
carbohydrate,  and  salts,  needs  attention  only  in 
a  general  way,  because  this  is  largely  regulated 
by  taste  and  custom.  For  example,  bread, 
which  contains  proteid  and  carbohydrate,  re- 
quires butter  (fat)  to  make  it  palatable;  meat, 
composed  of  fat  and  proteid,  requires  potato 
(carbohydrate)  to  please  the  taste.  The  cus- 
tomary combination  of  bread  and  butter,  meat 
and  potato,  bread  and  milk,  represents  physio- 
logical needs  which  taste  recognizes  and  con- 
trols. Mineral  salts  are  secured  through  milk, 
fruit,  and  the  green  vegetables. 

Essential  Foods. — Certain  foods  are,  how- 
ever, essential  to  proper  growth,  irrespective  of 
the  child's  taste.  If  milk  and  cereals  are 
omitted  from  the  diet,  it  is  difficult  to  keep  the 
daily  total  high  enough  for  continued  gain. 
Children  should  have  food  of  high  caloric  value, 
and  milk  supplies  this  need  as  well  as  providing 
all  the  required  food  elements.  Every  child 
should  have  at  least  a  pint  of  milk  a  day 
throughout  the  period  of  growth,  and  for  the 
undernourished  a  quart  is  better.  When  the 
taste  of  plain  milk  is  not  agreeable,  the  milk 

110 


DIET  AND  FOOD  HABITS 

may  be  flavored  with  a  little  malt  or  cane  sugar, 
or  taken  in  the  form  of  cocoa,  with  bread, 
crackers,  or  cereal,  in  the  sauce  for  vegetables. 


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FlGtTRE    19.      CEREAL   OMITTED 

Bertha's  mother  feared  oatmeal  was  too    "heatine"  and  omitted  It 
from  Bertha's  diet  the  first  week  in  .Tune.     The  chart  shows  a  con- 
sequent loss  in  weight  which  was  immediately  regained 
when  the  cereal  was  replaced  in  the  diet. 


or  in  purees  and  thick  soups.     When  used  in 
cooking  it  is  useful  in  increasing  the  nutritive 
value  of  various  dishes. 
Proteid  is  an  essential  food  constituent,  as 
111 


NUTRITION  AND  GROWTH  IN  CHILDREN 

new  cells  are  produced  by  proteid  only.  The 
tendency,  however,  even  among  the  poor,  is  to 
take  too  much  rather  than  too  little  proteid. 
Young  children  may  be  given  beef  juice  as  an 
appetizer,  and  a  small  amount  of  meat  will 
stimulate  growth,  but  at  no  age  is  the  excessive 
use  of  meat  either  economical  or  wholesome. 
Proteid  is  found  in  many  other  substances,  in- 
cluding milk,  eggs,  fish,  and  certain  vegetables.^ 

The  vitamin  Water-soluble  B  is  present  in 
so  many  articles  of  food  that  it  is  rarely  insuf- 
ficient in  the  American  diet.  Fat-soluble  A, 
which  is  less  widely  distributed,  is  present  in 
milk,  butter,  cream,  eggs,  animal  fat,  and  the 
leafy  vegetables.^ 

A  word  of  caution  is  needed  against  the  ex- 
cessive use  of  fruits  and  vegetables  in  the  effort 
to  supply  vitamins  in  the  child's  diet.  These 
are  foods  of  low  caloric  value,  which,  although 
supplying  essential  food  factors,  may  leave  the 
child  undernourished  due  to  an  insufficient  24- 
hour  amount.  It  is  better  to  safeguard  the  child 
in  this  respect  by  the  use  of  milk,  which  contains 
all  the  necessary  elements  and  is  a  food  of  high 
fuel  value. 

^  See  Table  of  Food  Values  with  percentage  of  proteid, 
fat,  and  carbohydrate  on  pp.  100-106. 

2  See  Table  of  Accessory  Food  Factors,  p.  177. 
112 


DIET  AND  FOOD  HABITS 

The  coarse  vegetables  are  valuable  for  fiber 
and  bulk,  to  offset  the  danger  of  too  coucen- 


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FiGtJKE  20.      CANDY   HABIT 

Marlon  ate  a  light  breakfast,  and  wben  she  became  hungry  In  the 
middle  of  the  morning,  satisfied  her  appetite  with  candy.  Thia 
spoiled  her  appetite  fo.  the  midday  meal.  Becoming  hungry  again 
In  the  afternoon,  she  ate  more  candy.  The  chart  shows  her  prompt 
gain  after  omitting  the  candy  and  eating  a  proper  amount  of 
wholesome  food — an  increase  of  7Vi   pounds  in  three  weeks. 

trated  foods.  Potatoes  are  especially  whole- 
some, and  should  be  eaten  at  least  once  a  day, 
preferably  at  the  midday  meal.  They  can  be 
prepared  in  many  ways,  and  are  one  of  the  best 

113 


NUTRITION  AND  GROWTH  IN  CHILDREN 

vehicles  for  the  consumption  of  milk,  cream, 
and  butter. 

Sweets. — Sweets  are  not  harmful  if  taken  at 
proper  times  and  in  moderate  amounts.  There 
is  no  evidence  that  sugar  is  injurious  in  its  ef- 
fects provided  it  is  diluted  and  balanced  by 
proteid  and  other  foods.  A  few  pieces  of  candy 
taken  as  a  dessert  will  add  to  the  number 
of  calories  without  impairing  the  digestion. 
Candy  is  clear  sugar,  however,  and  when  taken 
on  an  empty  stomach  acts  as  an  irritant,  caus- 
ing indigestion  and  consequent  loss  of  appetite. 
The  taking  of  too  much  sugar  leads  to  a  crav- 
ing for  sweets  and  a  disregard  for  the  natural 
flavor  of  other  wholesome  foods. 

Liquids  and  Mastication. — The  child  needs 
two  quarts  of  liquids  a  day,  and  therefore 
should  drink  plenty  of  water,  which  may  be 
cooled  but  should  never  be  iced.  This  may  be 
taken  before  and  after  meals,  and  during  the 
meal,  provided  there  is  no  food  in  the  mouth  at 
the  time. 

Food  should  be  chewed  as  long  as  there  is 
taste  in  it,  and  should  be  moistened  by  the  nat- 
ural secretions  of  the  mouth,  which  aid  diges- 
tion. The  habit  of  washing  down  food  with 
liquids  leads  to  imperfect  assimilation,  and 
where  this  practice  has  been  established,  ail 

114 


DIET  AND  FOOD  HABITS 

liquids  shoud  be  placed  out  of  the  child  *s  reach 
until  the  habit  is  broken. 


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FiGUEE  21.      FAST  EATING 

Charles,  at  the  age  of  eight,  was  underweight  nearly  10  pounds.     At 

54  pounds  he  stopped  Rainlnff.     Such  a  failure  to  gain  Indicates  a 

relative  lose,   as  wels^ht  should   Increase  steadily   durlnz   childhood. 

The  cause  in  this  case  was  fast  eating.     When  Charles  was 

induced  to  eat  slowly,  his  weight  Increased  rapidly. 

Milk  is  a  food,  and  therefore  should  not  be 
used  to  quench  thirst.  It  should  be  taken 
slowly,  preferably  with  a  spoon;  for  example, 
on  cereal  or  in  the  form  of  bread  and  milk. 

115 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Growing  children  should  not  be  allowed  to  drink 
tea  or  coffee. 

Fast  Eating. — Every  meal  should  take  at 
least  20  minutes  by  the  clock,  and  the  child 
should  sit  through  to  the  end  with  the  rest  of 
the  family.  The  pernicious  habit  of  fast  eating 
is  one  of  the  most  difficult  to  correct,  and  where 
a  child  has  formed  the  habit,  it  may  be  neces- 
sary to  begin  all  over  again  and  teach  him  how 
to  eat,  just  as  one  teaches  an  infant.  One  help- 
ful device  is  to  give  him  a  small  fork  and  spoon, 
such  as  an  oyster  fork  or  an  after-dinner  coffee 
spoon,  and  thus  cut  down  automatically  the 
amount  of  food  he  can  put  into  his  mouth  at  one 
time.  The  child  will  often  be  amused  and  inter- 
ested by  these  special  utensils  of  his  own,  but  if 
such  measures  are  not  successful,  it  may  be 
necessary  for  some  other  person  to  feed  him 
for  a  sufficient  time  to  overcome  the  habit. 

The  Family  Table. — The  question  is  often 
asked  whether  it  is  better  that  a  child  should 
eat  alone  in  the  nursery  or  have  his  meals  with 
the  other  members  of  the  family.  Children 
need  companionship  at  their  meals  as  at  other 
times,  and  there  is  an  educational  value  in  the 
ordinary  associations  of  well  regulated  family 
life  which  should  not  be  overlooked.  A  child 
will  imitate  an  older  boy  or  girl,  and  thus  learn 

116 


DIET  AND  FOOD  HABITS 

to  eat  new  kinds  and  quantities  of  food  that 
would  be  refused  under  other  conditions. 

Loss  of  Appetite — Its  Cause  and  Its  Cure. — 
If  a  growing  child  has  no  desire  to  eat,  there  is 
always  an  adequate  cause  for  his  lack  of  ap- 
petite. The  small  appetite  is  often  a  provision 
of  nature  to  prevent  overeating  when  tired,  thus 
causing  indigestion.  "Too  tired  to  eat"  is  a 
frequent  condition  with  malnourished  children. 
Another  cause  of  poor  appetite  is  irregular  eat- 
ing. For  example,  a  small  breakfast  and  a 
heavy  dinner  is  like  giving  an  infant  two  ounces 
at  one  feeding  and  twelve  at  the  next.  Irregular 
intervals  between  meals,  and  the  practice  of 
nibbling  food  all  through  the  day  interferes 
with  the  appetite  for  the  next  meal.  The  serv- 
ing of  too  large  a  portion  will  sometimes  cause 
a  child  to  eat  less  than  he  would  if  a  smaller 
amount  were  offered. 

The  state  of  the  child's  mind  may  prevent 
his  eating  properly.  Many  children  would 
rather  play  than  eat,  and,  with  minds  intent 
upon  their  games,  will  run  from  the  table  be- 
fore they  have  taken  sufficient  food.  Unhappi- 
ness  and  worry,  often  unsuspected  by  parents, 
are  also  causes  of  a  loss  of  appetite.  While 
the  parents  should  know  what  is  best  for  the 
child,  and  should  see  that  their  program  is  car- 

117 


NUTRITION  AND  GROWTH  IN  CHILDREN 

ried  out,  the  joy  and  satisfaction  of  the  meal 
should  not  be  spoiled  by  constant  nagging. 

A  large  group  of  '*no  appetite"  cases  are 
caused  by  the  effect  of  drugs.  The  most  com- 
mon of  these  is  caffein  from  coffee  and  tea.  A 
third  of  a  cup  of  tea  contains  about  one  grain 
of  the  drug,  as  much  as  is  given  in  an  average 
dose  for  medicinal  purposes.  Records  from 
our  clinics  in  Boston,  New  York,  and  Chicago 
show  that  about  85  per  cent  of  the  malnourished 
children  treated  used  tea  or  coffee  or  both,  one 
or  more  times  each  day. 

Among  older  children  there  is  more  trouble 
from  nicotine  than  most  parents  realize,  espe- 
cially among  boys  and  girls  who  are  allowed  to 
smoke  at  the  age  of  sixteen  to  twenty,  before 
their  period  of  growth  is  complete.  The  most 
remarkable  fact  about  all  these  drugs  is  their 
baneful  effect  upon  growing  tissue,  while  con- 
siderable amounts  can  be  used  in  later  life  w^th 
no  apparent  harm.  An  exception  to  this  latter 
statement  must  be  made  in  the  case  of  coffee, 
where  the  aromatic  oils  are  frequently  the 
cause  of  indigestion. 

There  are  disadvantages  arising  from  the  ar- 
rangement of  many  modern  homes,  in  which 
the  kitchen  is  so  far  removed  from  the  scene  of 
the  child's  activities  that  he  does  not  get  the 

118 


DIET  AND  FOOD  HABITS 

healthy  stimulation  of  appetite  that  comes,  for 
example,  from  the  odors  of  baking.  If  he  can 
see  and  smell  food  in  the  process  of  preparation, 
the  desire  to  taste  will  naturally  follow.  This 
is  exemplified  in  camp  life  where  children  eat 
plain  coarse  food  with  more  zest  than  they  have 
for  the  dainties  of  the  richest  home  table.  The 
gains  made  in  these  summer  camps  are  due 
quite  as  much  to  the  increased  food  and  normal 
associations  with  other  children  as  they  are  to 
the  air  and  exercise. 

It  is  fatal  to  force  feeding  when  the  child  is 
not  hungry.  If  he  does  not  feel  equal  to  eating 
a  proper  amount,  his  activities  should  be  limited 
so  that  he  will  not  use  up  his  scant  supply  of 
energy.  He  should  be  restrained  from  activity 
before  breakfast  in  particular,  as  inadequate 
breakfasts  are  more  frequently  reported  in  the 
diet  lists  than  insufficient  meals  at  any  other 
time.  When  the  child  refuses  his  breakfast  he 
should  be  put  to  bed,  and  kept  there  until  his 
appetite  returns  or  the  cause  is  found.  It 
should  be  made  certain  that  this  lack  of  appe- 
tite in  the  morning  is  not  due  to  bad  air  in  the 
sleeping  room,  or  to  a  catarrhal  discharge  from 
the  naso-pharynx  during  the  night. 

Food  Aversions. — In  the  case  of  undernour- 
ished  children,   food   prejudices,   aversion   to 

119 


NUTRITION  AND  GROWTH  IN  CHILDREN 

form,  taste,  or  smell,  or  the  association  of  cer- 
tain foods  with  unpleasant  events,  may  be 
almost  insurmountable  obstacles  in  securing 
proper  nutrition.  Among  girls,  especially,  the 
appetite  is  fickle,  leading  them  to  choose  carbo- 
hydrates almost  wholly,  and  to  take  far  too  low 
a  percentage  of  proteid  and  the  leafy  vegetables 
for  proper  growth. 

This  distaste  for  certain  vegetables  can  often 
be  corrected  by  a  change  in  the  method  of  pre- 
paring or  combining  them.  A  creamed  sauce 
will  not  only  add  agreeably  to  their  flavor,  but 
also  enhance  their  food  value.  By  combining 
peas  with  carrots,  and  corn  with  potatoes  or 
beans,  the  child  can  be  trained  to  like  vegetables 
in  increasing  variety.  With  the  ordinary 
standard  foods  it  is  proper  to  require  the  child 
to  take  a  small  portion  of  something  which  he 
thinks  he  dislikes  in  order  to  rid  him  of  the  idea 
that  he  cannot  eat  it,  but  to  compel  him  to  make 
a  whole  meal  out  of  foods  for  which  he  has  no 
taste  is  to  risk  establishing  a  permanent 
antipathy. 

There  is  great  danger  that  the  child  with  a 
poor  appetite  will  unconsciously  eliminate  one 
good  food  after  another,  so  that,  amidst  plenty, 
he  may  come  to  live,  as  stated  by  McCollum,' 

3  E.  V.  McCollum,  "The  Newer  Knowledge  of  Nutrition." 
120 


DIET  AND  FOOD  HABITS 

on  a  dangerously  restricted  diet  consisting  of 
muscle  meat,  white  bread,  and  potato,  with  only 
the  variety  that  results  from  other  foods  of  a 
like  nature  such  as  degerminated  cereals,  sugar, 
and  the  tuber  vegetables. 

Food  should  never  be  used  as  a  vehicle  for 
medicine.  This  practice  sometimes  causes 
aversions  that  persist  throughout  life,  which 
are  all  the  more  serious  in  their  consequences 
because  the  foods  disliked  are  apt  to  be  those  of 
high  caloric  value. 

There  are  other  food  aversions  due  to  the 
idiosyncrasy  of  the  individual  in  regard  to  par- 
ticular foods,  which  must  be  regarded  as  cases 
of  food  poisoning  and  be  treated  as  such  under 
the  advice  of  a  physician.  For  example,  some 
children  are  poisoned  by  strawberries,  eggs, 
lobster,  or  the  proteins  of  various  other  foods. 
This  condition,  which  is  known  as  anaphylaxis, 
cannot  be  traced  to  its  cause  in  many  cases 
without  a  series  of  cutaneous  food  tests.  It 
should  not  be' assumed  as  the  basis  for  the  food 
prejudices  of  the  child  until  such  an  examina- 
tion has  proved  it  to  be  the  case. 

It  is  universally  recognized  that  the  appear- 
ance and  health  of  an  animal  depend  on  the  food 
and  the  care  which  he  receives ;  but  a  child  may 
be  '' dragged  out,"  irritable  and  fault-finding, 

121 


NUTRITION  AND  GROWTH  IN  CHILDREN 

and  it  is  assumed  that  this  is  a  natural  state  for 
the  growing  boy  and  girl.  More  progress  has 
been  made  in  the  feeding  of  animals  than  in 
that  of  man.  Regularity,  smaller  and  more 
frequent  feedings,  enough  food  without  waste, 
and  the  importance  of  clearing  up  at  each  meal 
what  has  been  provided  are  recognized  stand- 
ards in  animal  feeding.  All  these  principles 
are  equally  applicable  to  the  feeding  of  chil- 
dren. Many  parents  resent  being  reminded  that 
their  children  are  young  animals,  but  there 
would  be  less  malnutrition  if  this  truth  were 
better  realized. 


CHAPTER  XII 

HEALTH   HABITS 

In  bringing  the  undernourished  child  up  to 
his  normal  weight,  attention  must  be  focused, 
not  only  upon  food  and  food  habits,  but  upon 
such  other  fundamentals  of  health  as  rest,  fresh 
air,  bathing,  and  proper  clothing.  It  is  neces- 
sary to  look  into  every  detail  of  a  child's  life 
to  find  the  cause  of  malnutrition,  and  except 
where  there  is  a  single  conspicuous  obstacle  to 
health,  this  cause  is  frequently  found  to  be  the 
neglect  to  establish  sound  health  habits  in  sim- 
ple but  essential  matters. 

Dr.  Rene  Sand  of  Brussels  reports  that  the 
war  has  caused  at  least  a  year's  retardation  in 
the  growth  of  children  in  Belgium.  With  this 
heavy  burden  added  to  the  malnutrition  already 
present  before  the  war,  a  condition  exists  that 
no  mere  supplying  of  additional  food  will  cor- 
rect. It  can  be  cured  only  by  special  instruc- 
tion in  rest  and  other  fundamental  health 
habits. 

The  subject  should  be  approached  in  the  be- 
lief that  nature  always  makes  for  health,  and 

123 


NUTRITION  AND  GROWTH  IN  CHILDREN 

usually  succeeds  unless  there  are  conditions  too 
unfavorable  for  her  to  overcome. 

Fresh  Air. — In  the  treatment  of  malnourished 
children  we  have  found  that  those  who  sleep 
on  porches  or  under  window  tents  gain  in 
weight  faster  than  those  who  sleep  in  a  room 
with  several  windows  open.  It  is  of  equal  im- 
portance that  as  much  time  as  possible  should 
be  spent  in  the  open  air  during  the  day,  and 
the  hours  of  sunlight  are  particularly  desirable. 
This  w^as  illustrated  in  the  case  of  a  group  of 
12  children,  who  had  been  gaining  well  until 
there  came  a  week  of  daily  storms.  These  chil- 
dren were  in  an  institution  where  the  ventila- 
tion was  as  nearly  perfect  as  possible,  and  in 
their  playroom  the  windows  were  wide  open; 
yet  every  child  stopped  gaining,  and  some  be- 
gan to  lose  because  they  were  not  able  to  be 
actually  out  of  doors. 

Open-air  schools  were  originally  intended 
only  for  children  below  par,  but  it  is  now  real- 
ized that  conditions  which  make  the  sick  well 
are  favorable  for  all.  It  has  been  found  that 
pupils  who  make  rapid  gains  in  weight  in  open- 
air  classes  begin  to  lose  as  soon  as  they  return 
to  the  ordinary  shut-in  type  of  schoolroom. 
Open-air  schools  do  a  further  service  in  reduc- 
ing contagion,  which  is  of  importance  at  all 

124 


HEALTH  HABITS 

times,  but  especially  during  such  a  widespread 
danger  as  the  influenza  epidemic  of  1918.  An 
open-air  school  observed  at  that  time  went 
through    the    epidemic    with    scarcely   a    case 


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Esther  slept  In  a  room  with  four  other  peraons  with  the  windows 
closed.  She  also  bad  the  habit  of  keeping  her  head  under  the 
blankets.  Iler  parents  were  prejudiced  against  cold  air  at  night,  but 
agreed  to  have  the  windows  open  when  Esther  failed  to  sain.  Thia 
also  induced  her  to  keep  her  head  outside  the  bed  clothing, 
and  she  soon  made  a  good  gain  in  weight. 


among  teachers  or  pupils,  while  neighboring 
schools  were  obliged  to  close. 

Indoor  temperature  should  not  be  kept  above 
68  or,  at  most,  70  degrees.    Experiments  show 

125 


NUTRITION  AND  GROWTH  IN  CHILDREN 


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FlGUKE   23.      A   SO-CALLED   "PEE-TUBERCULAB"   CHILD 


Perry  C.  was  under  constant  observation  at  the  New  England  Home 
for  Little  Wanderers,  and  his  ohart  illustrates  a  number  of  the 
most  common  causes  that  affect  nutrition.  His  first  failure  to  gain 
occurred  in  the  week  of  December  20,  and  was  traced  to  over- 
indulgence in  apples  between  meals.  A  barrel  that  had  been  sent 
as  a  holiday  gift  was  left  open  where  he  could  help  himself.  By 
eating  apples  freely  he  took  less  of  more  nourishing  foods,  and  lost 
one-half  ^ound.  January  31  and  February  7  he  failed  to  gain 
because  of  playing  with  another  boy  during  "rest  periods.  February 
21  was  a  week  when  the  extra  lunches  were  omitted.  The  week 
of  March  1.3  it  stormed  every  day,  and  he  could  not  play  outdoors. 
During  "apple  week,"   the  week  when   lunches   were  omitted,   and 

that  both  children  and  adults  fall  off  in  their 
working  efficiency  as  soon  as  the  temperature 

126 


HEALTH  HABITS 


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thp  week  of  bad  weather  all  others  In  the  class  failed  to  gain  for 
the    same    reason. 

As  Perry  had  made  no  marked  increase  over  the  normal  rate  of 
pain  from  January  24  to  April  3.  it  was  decided  that  his  tonsils, 
which  were  cryptic,  might  be  the  disturbiu.sr  cause.  The  tonsils 
were  removed,  but  he  was  kept  in  bed  only  two  days,  and  lost  five 
pounds.  He  regained  this  weight,  and  continued  to  gain  until 
May  8,  when  as  a  result  of  returning  to  school  he  made  no  gain. 
June  12  shows  the  effect  of  overeating  at  a  picnic.  July  3  he 
reached  normal  weight  for  his  height,  and  was  in  excellent  con- 
dition. Perry's  mother  had  died  of  tuberculosis.  Good  nutrition 
is  the  best  safeguard  against  this  disease. 

rises  above  this  point.    Another  bad  condition 
is  the  dryness  of  an  overheated  room,  and  some 

127 


NUTRITION  AND  GROWTH  IN  CHILDREN 

means  should  be  provided  for  adding  moisture 
to  the  air.  Moist  air  at  a  low  temperature  is 
not  only  more  healthful,  but  far  more  comforta- 
ble, than  dry  air  at  a  high  temperature.  Air 
in  motion  is  better  than  still  air,  and  electric 
fans  and  other  devices  for  keeping  air  in  circu- 
lation have  a  value  beyond  the  immediate  com- 
fort they  afford. 

It  is  dangerous  to  allow  a  sudden  chilling  of 
the  body,  as  this  lowers  the  resistance  to  bac- 
teria which  cause  various  forms  of  infection. 
But  a  fear  of  drafts  usually  indicates  a  condi- 
tion of  sensitiveness  that  ought  to  be  looked 
into  and  corrected.  There  is  no  danger  from 
open  windows  at  night  if  protection  from  a 
direct  draft  is  secured  by  means  of  screens  or 
by  a  blanket  placed  over  a  chair  by  the  bedside. 
It  is  not  enough  that  the  windows  of  the  sleep- 
ing room  should  be  open,  but  the  air  must  actu- 
ally circulate.  For  this  reason  windows  on  two 
sides,  which  permit  a  cross  current,  are  desira- 
ble. Where  the  bed  is  in  a  corner  or  an  alcove, 
it  should  be  drawn  out  at  night,  because  several 
hours  may  otherwise  pass  before  the  air  about 
the  bed  is  completely  changed. 

Drugs  Unnecessary. — In  many  families  it  is 
still  the  custom  to  give  a  child  medicines  strong 

128 


HEALTH  HABITS 

enough  to  do  injury  to  an  adult.  The  tempta- 
tion most  commonly  appears  in  a  supposed  need 
for  tonics  and  laxatives.  Tonics  are  rarely 
necessary,  and  should  be  given  only  when  there 
is  an  adequate  reason.  If  the  child  has  a  suf- 
ficient variety  of  food,  he  will  be  supplied  with 
all  the  iron  and  salts  he  requires. 

Good  health  habits  and  proper  food  make  the 
use  of  laxatives  unnecessary.  There  should  be 
a  regular  time  for  the  bowels  to  move,  at  least 
once  a  day,  preferably  just  after  breakfast, 
when  the  mother  should  see  that  the  child  is 
free  from  hurry,  worry,  or  nagging.  Many 
mothers  are  so  fearful  that  the  child's  bowels 
will  not  move  that  they  continue  to  give  cathar- 
tics when  there  is  no  possible  need.  If  the  daily 
movement  is  skipped  occasionally,  it  does  not 
necessarily  mean  harm. 

If  a  drug  has  been  used  and  the  habit  formed, 
the  dose  should  be  gradually  reduced  until  the 
habit  is  entirely  broken.  The  only  exception 
that  should  be  made  is  in  a  case  of  acute  in- 
digestion, when  a  tablespoonful  of  castor  oil 
given  immediately  will  remove  the  undigested 
food  and  enable  the  child's  digestion  to  begin 
anew. 

The  growing  child  does  not  need  drugs,  all 
129 


NUTRITION  AND  GROWTH  IN  CHILDREN 

of  which  are  pernicious  when  taken  habitually. 
There  should  be  an  abundance  of  fruit  and 
coarse  vegetables  in  the  diet,  and  a  further  help 
is  the  drinking  of  plenty  of  water,  especially 
before  breakfast. 

Care  of  the  Teeth. — Children  should  be  taught 
the  use  of  the  toothbrush  from  their  earliest 
years,  and  at  the  first  signs  of  decay  they  should 
be  taken  to  a  dentist  to  have  the  teeth  filled  or 
extracted.  Even  baby  teeth  can  be  treated  and 
cared  for.  Infections  about  the  roots  interfere 
with  growth  and  if  neglected  may  lead  to  seri- 
ous complications. 

The  Right  Kind  of  Clothing. — The  malnour- 
ished child  needs  more  clothing  than  the  well 
child  in  order  to  keep  the  body  warm.  One  of 
the  physical  signs  of  malnutrition  is  cold  hands 
and  feet,  which  indicates  impaired  circulation. 
Extra  care  should  be  taken  in  winter,  especially 
when  the  child  sleeps  in  the  open.  Blankets  or 
newspapers  should  be  put  under  the  mattress, 
because  if  there  is  insufficient  protection  from 
below,  no  amount  of  covering  will  keep  the 
child  warm.  As  a  matter  of  routine,  a  hot- 
water  bottle  should  be  put  into  the  bed  at  night, 
well  down  in  the  corner  where  the  feet  will  not 
touch  it  unless  its  warmth  is  needed. 

During  the  day  there  should  be  only  enough 
130 


HEALTH  HABITS 

indoor  clothing  to  keep  the  body  warm  without 
causing  perspiration.  Coarse-meshed  cotton  or 
linen  underwear  is  better  than  woolen,  because 
it  permits  greater  circulation  of  air ;  but  in  win- 
ter the  outer  garments  should  be  of  wool,  and 
woolen  stockings  should  be  worn.  Sudden 
changes  of  clothing  must  be  avoided,  such  as 
the  change  from  heavy  to  light  underwear,  and 
from  high  to  low  shoes. 

Above  all,  children's  clothing  should  be  com- 
fortable, and  adapted  to  the  changing  demands 
of  play,  rest,  indoor  and  outdoor  activities. 
Many  mothers  are  too  much  concerned  with  ap- 
pearances. Irritating,  stiff  collars,  and  clothes 
which  the  child  has  to  worry  about,  are  a  direct 
cause  of  ill  health.  Children  outgrow  their 
clothes  faster  than  may  be  realized,  and  tight 
clothing  is  a  cause  of  serious  discomfort.  This 
should  be  specially  guarded  against  in  collars 
and  shoes. 

Children's  shoes  should  be  of  the  straight 
last  type,  with  ample  room  for  movement  of 
the  toes  so  that  the  joints  will  not  be  displaced 
or  the  circulation  impaired.  The  feet  should 
not  be  allowed  to  become  chilled  from  damp- 
ness, and  rubbers  or  rubber  boots  should  be 
worn  whenever  the  ground  is  wet.  In  unavoida- 
ble cases  of  wet  feet,  both  stockings  and  shoes 

131 


NUTRITION  AND  GROWTH  IN  CHILDREN 

should  be  changed  without  delay.  Many  serious 
infections  result  from  the  neglect  of  these  sim- 
ple precautions. 

Bathing. — The  child  should  be  taught  to  bathe 
properly.  He  should  be  thoroughly  clean  in  the 
morning  and  at  night,  and  the  hands  should  be 
washed  carefully  before  every  meal.  A  cold 
chest  bath  in  the  morning  serves  to  harden  the 
skin  and  to  protect  against  changes  in  tempera- 
ture. A  warm  neutral  bath  at  night  is  good, 
and  if  the  child  is  very  tired  a  hot  bath  will 
restore  the  circulation  and  give  rest  without 
over-stimulation. 

The  malnourished  child  often  has  poor  circu- 
lation. For  this  reason  swimming  in  cold  water, 
either  fresh  or  salt,  should  be  indulged  in  with 
great  caution.  The  test  is  the  condition  shown 
when  he  comes  out  of  the  water.  If  he  is  shiver- 
ing and  blue,  the  bath  does  him  harm.  On  the 
other  hand,  if  his  reaction  is  good,  his  skin 
glowing  and  red,  the  effect  is  beneficial. 

Rubbing  is  of  special  value  in  connection  with 
all  bathing,  as  it  increases  the  activity  of  the 
skin,  and  helps  in  eliminating  waste  matter 
from  the  body.  The  bath  and  rub-down  which 
have  become  a  regular  feature  of  college  ath- 
letics are  equally  to  be  recommended  for  the 
child  who  comes  in  perspiring  and  tired  from 

132 


HEALTH  HABITS 

his  play.  In  either  case  a  short  rest  immedi- 
ately after  the  bath  will  add  to  its  good  effect. 

Habits  and  Health. — It  has  been  rightly  said 
that  one  who  is  well  at  eighteen  will  probably 
remain  well  the  rest  of  his  life.  This  is  but  to 
recognize  the  influence  of  habit,  and  it  should 
also  be  recognized  that  it  is  as  easy  for  the 
child  to  form  good  health  habits  as  bad.  If 
good  habits  are  established  in  childhood,  we 
may  be  confident  that  good  health  will  result. 
When  a  child  is  not  well,  irregular  and  wrong 
habits  must  be  looked  for;  and,  on  the  other 
hand,  where  we  find  healthy,  happy  children, 
well  nourished  and  up  to  normal  weight,  it  is 
almost  certain  that  the  essentials  of  health  are 
being  maintained  by  regular  meals,  regular 
work  and  play,  regular  rest  and  sleep,  and 
regular  bodily  functions. 

The  matter  of  rest  and  sleep  is  of  so  much 
importance  that  it  is  treated  separately  in  the 
chapter  on  overfatigue. 


CHAPTER  XIII 


EXERCISE   AND   RECREATION 


In  caring  for  an  undernourished  child  it  is 
easy  to  forget  the  importance  of  exercise  and 
play.  Children  who  are  not  strong  naturally 
turn  to  reading  and  indoor  occupations,  and 
thus  are  deprived  of  the  benefit  of  outdoor  ac- 
tivity. But  they  need,  even  more  than  the  well 
child,  to  spend  as  many  hours  of  the  day  as 
possible  in  the  open  air.  In  cold  weather  they 
should  play  games  with  sufficient  activity  to 
keep  them  warm,  but  at  all  times  they  should  be 
guarded  carefully  against  overfatigue. 

Training  in  Play. — There  is  wonderful  train- 
ing for  the  powers  of  the  growing  child  in  play. 
Free  play  is  constructive,  and  calls  into  opera- 
tion the  various  mental  and  physical  capacities. 
Children  should  be  encouraged  to  work  out  their 
games  in  their  own  way  without  too  close  or  too 
constant  supervision  by  adults.  In  this  way 
they  learn  to  discipline  themselves  and  one  an- 
other. During  the  early  years  interest  centers 
in  imitating  the  activities  of  older  persons,  but 
at  the  age  of  seven  or  eight  the  spirit  of  com* 

134 


EXERCISE  AND  RECREATION 

petition  develops,  and  foundations  are  laid  for 
association  and  team  play. 

In  the  World  War  it  was  shown  that  the 
strategy  worked  out  in  games  was  adapted  to 
the  serious  purpose  of  war  maneuvers.  The 
play  of  the  boy  became  the  work  of  the  man, 
and  some  of  the  best  achievements  were  made  by 
young  athletes  of  trained  eye  and  muscle  but 
with  no  previous  military  experience. 

Nothing  is  more  pathetic  than  the  child  who 
has  never  learned  to  play.  Many  of  the  nervous 
breakdowns  of  later  life  occur  because  men  and 
women  who  failed  to  form  the  habit  of  play  in 
childhood  pursue  their  work  intensely  without 
recognizing  the  need  for  adequate  recreation 
and  exercise.  The  habit  of  play  is  a  permanent 
safeguard  to  health. 

The  Need  of  Moderation. — The  danger  in 
play  for  the  undernourished  child  is  that  he  will 
engage  in  games  beyond  his  strength,  or  indulge 
in  them  for  too  long  a  time  without  rest.  It  is 
better  for  him  to  begin  with  simple  and  easy 
games,  and  gradually  work  up  to  those  which 
make  greater  demands  upon  him.  A  boy  who 
is  underweight  should  not  take  part  in  tourna- 
ments or  in  such  strenuous  games  as  football, 
wherein  much  endurance  is  required.  Running 
races    should   also   be   avoided,    and   bicycling 

135 


NUTRITION  AND  GROWTH  IN  CHILDREN 

should  be  limited  to  short  rides  without  heavy 
grades. 

Skating,  coasting,  sailing,  canoeing,  baseball, 
tennis — if  the  time  is  limited  in  each  case  to 
the  child's  endurance — are  all  beneficial  and 
productive  of  growth.  Cross-country  walking 
is  an  excellent  form  of  exercise,  bringing  many 
muscles  into  service.  The  hard  pavement  of 
city  streets,  however,  results  in  a  monotonous 
repetition  of  the  same  steps,  thus  exercising 
fewer  muscles  and  causing  early  fatigue. 
Nurse  maids  often  allow  a  child  of  pre-school 
age  to  exceed  his  strength  in  this  way,  and  thus 
cause  serious  harm. 

In  general,  the  underweight  child  should 
avoid  competitive  games  and  should  be  encour- 
aged to  turn  to  sports  requiring  skill  rather 
than  strength. 

Gymnasium  work  is  not  to  be  recommended 
for  underweight  children,  and  is  never  a  desira- 
ble substitute  for  play  in  the  open  air.  For 
older  boys  and  girls  formal  gymnastics  and 
rhythmic  exercises  are  useful  as  a  means  of 
securing  poise  and  control,  and  provide  a  source 
of  body  development  during  the  seasons  when 
the  opportunity  for  outdoor  sports  is  limited. 
Dancing,  especially  folk-dancing  and  the  forms 
that  bring  about  a  higher  degree  of  muscular 

136 


EXERCISE  AND  RECREATION 

control,  may  be  safely  indulged  in  with  modera- 
tion. 

All  forms  of  exercise  should  be  made  an  edu- 
cation as  well  as  a  recreation.  There  is  always 
a  right  and  a  wrong  way  to  do  things.  One  can 
learn  to  climb  a  mountain,  ''taking  it  easy," 
with  less  fatigue  than  will  follow  a  shorter 
climb  taken  impetuously  and  without  proper 
rests.  The  field  contests  outlined  by  the  Boy 
and  Girl  Scouts  offering  opportunity  for  plan- 
ning and  invention  are  particularly  suitable  for 
underweight  children  because  they  require  less 
physical  energy  than  ordinary  sports. 

Corrective  Exercises. — There  has  been  a  tend- 
ency to  over-rate  the  importance  of  corrective 
exercises.  It  should  be  recognized  that  most 
cases  of  bad  posture  are  due  to  the  general 
weakness  of  a  body  with  too  little  weight  to 
support  its  height.  Where  this  condition  exists, 
the  first  need  is  to  start  the  child  on  a  program 
that  will  bring  him  up  to  his  normal  weight, 
when  it  will  be  found  that  as  weight  increases, 
the  posture  improves. 

Where  formal  exercises  are  needed  to  correct 
wrong  postural  habits,  or  to  remedy  deformi- 
ties, it  should  be  made  certain  that  the  child 
takes  extra  rest  j)eriods  to  offset  the  fatigue  of 
the  exercises.    But  where  the  postural  defects 

137 


NUTRITION  AND  GROWTH  IN  CHILDREN 

are  due  to  overfatigue  and  underweight,  the 
extra  strain  of  corrective  exercises  will  simply 
add  to  his  burden  and  aggravate  his  condition. 
Here,  as  elsewhere,  any  constant  expenditure 
of  energy  that  is  greater  than  the  amount  pro- 
duced can  only  result  in  lowered  vitality  and 
failure  to  attain  the  object  sought. 

After  the  child  has  gained  normal  weight  and 
his  muscles  have  recovered  tone,  then  corrective 
exercises  are  of  great  benefit. 

Indoor  Amusements. — The  movie  and  theater 
habits  are  unsuitable  forms  of  entertainment 
for  the  growing  child  on  account  of  the  bad  air, 
danger  of  eye  strain,  over-stimulation  of  the 
nervous  system,  and  fatigue  from  prolonged 
attention. 

Reading  and  table  games  afford  recreation 
without  bodily  fatigue,  and  are  a  valuable  alter- 
native to  physical  activity.  There  is  danger  of 
excess  even  here,  however,  and  neither  games 
nor  books  should  be  made  the  excuse  for  late 
hours.  Reading  is  not  resting,  and  the  child 
should  not  be  allowed  to  read  when  lying  down. 
Instead  of  bringing  rest  and  repose  this  habit 
strains  the  eye  muscles  and  stimulates  nervous 
reactions. 

A  Health  Program  for  the  Summer. — Sum- 
mer time  is  especially  favorable  for  physical 

138 


EXERCISE  AND  RECREATION 

growth,  and  the  best  season  in  which  to  start  a 
program  to  bring  the  malnourished  child  up  to 
his  normal  weight.  Freedom  from  the  strain 
of  schoolwork  and  many  other  conditions  that 
cause  overfatigue,  together  with  the  greater  op- 
portunity for  outdoor  life  and  more  varied  diet, 
result  in  height  and  weight  gains  beyond  those 
of  any  other  time  of  the  year.  Porter  has  shown 
by  the  measurements  of  thousands  of  Boston 
school  children  that  two-thirds  of  the  gain  in 
weight  for  the  year  is  accomplished  from  June 
to  January.^ 

During  the  summer  season  it  should  be  possi- 
ble for  the  undernourished  child  to  spend  prac- 
tically all  his  time  out  of  doors.  Arrangements 
for  sleeping  out  can  easily  be  made.  If  there  is 
no  available  porch,  a  small  shelter  tent  can  be 
erected  and  equipped  in  the  yard,  or  a  camp  can 
be  organized  in  a  vacant  lot  within  reach  of  the 
home. 

Vacation  trips  to  the  mountains,  the  shore, 
or  the  country  bring  new  opportunities  for  ex- 
ercise in  the  open  air,  and  develop  an  interest  in 
new  forms  of  sport.  When  longer  vacations  are 
not  possible,  a  day's  outing,  or  even  an  after- 

^.  iW.  T  Poi-ter,  "The  Seasonal  Variation  in  the  Growth 
of  Boston  School  Children  "  American  Journal  of  Physiol- 
ogy, Vol.  52,  No.  1,  pp.  121-131,  May,  1920. 

139 


NUTRITION  AND  GROWTH  IN  CHILDREN 

noon's  walk  in  the  country,  can  be  made  an  oc- 
casion for  real  refreshment  if  it  is  taken  in  a 
holiday  spirit,  with  the  children's  interest  di- 
rected into  new  channels.  Eating  out  of  doors 
is  always  an  aid  to  appetite,  and,  if  a  further 
excursion  is  not  possible,  a  porch  picnic  will 
prove  to  be  a  pleasant  break  from  the  indoor 
routine. 

The  element  of  enjoyment  is  necessary  for 
the  best  results  from  any  of  these  forms  of 
recreation,  just  as  it  is  the  spirit  of  play  in 
games  and  sports  that  makes  them  more  bene- 
ficial to  the  participant  than  formal  exercises 
and  gymnastics. 

The  Benefits  of  the  Summer  Camp. — Even  a 
brief  stay  in  a  well  organized  summer  camp  is 
a  valuable  experience,  and  may  be  the  means  of 
breaking  up  bad  food  and  health  habits,  and 
giving  the  child  a  new  interest  in  his  own  health. 
The  temporary  separation  from  home  and  fam- 
ily is  beneficial  in  introducing  the  child  to  a 
larger  world  in  which  his  comfort  will  largely 
depend  on  his  own  efforts.  The  ''only  child" 
who  has  suffered  from  the  excessive  care  of  a 
too  indulgent  home  has  a  fear  of  independent 
action  which  camp  life  quickly  removes.  He 
soon  learns  to  "paddle  his  own  canoe"  and  if 
he  finds  himself  lacking  in  the  vigor  required 

140 


EXERCISE  AND  RECREATION 

for  the  hikes  or  sports  of  his  mates,  he  will  at 
once  begin  to  take  a  keen  interest  in  his  physi- 
cal development. 


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Figure  24.    gain  at  a  girls'  camp 

This  chart  sbows  (he  averagp  gala  of  a  group  of  30  girls  at  the 
Arden  Shore  class  iif  tho  Elizabeth  Mct'ormick  Memorial  Fund, 
Chicago,  maintaiued  for  those  who  apply  for  working  certificates 
but  are  not  up  to  uornial  weight,  'i'he  girls  were  put  on  our 
nutrition  ijrogram,  and  their  activities  were  regulated  according  to 
their  individual  weight  chai'ts.  The  group  gain  of  650  per  cent  of 
the  average  rate  of  growth  illustrates  the  results  that  can  be 
obtained  by  such  a   program   witliout  additional   expense  for  food. 


Here,  too,  he  learns  what  real  hunger  means, 
and  has  to  do  his  share  of  the  necessary  tasks 
before  his  appetite  is  satisfied.    A  boy  or  girl 

141 


NUTRITION  AND  GROWTH  IN  CHILDREN 

who  spends  even  a  fortniglit  in  direct  relation 
with  the  necessities  of  life,  taking  part  in  the 
preparation  of  food  and  the  provision  of  shel- 
ter and  warmth,  has  a  different  outlook  ever 
after. 

Leadership  in  the  camp  personnel  is  of  great 
importance  in  bringing  the  child  under  the  in- 
fluence of  high  ideals  of  right  living.  But  of 
hardly  less  importance  is  the  proper  equix)ment 
of  the  camp  with  scales,  and  the  recognition  of 
periodic  weighing  as  the  surest  test  of  the 
child's  condition.  The  nutrition  program,  with 
its  alternations  of  activity  and  rest,  with  regular 
hours  for  meals  and  lunches,  can  be  easily 
adapted  to  the  camp  schedule,  and  the  child's 
gain  or  loss  in  weight  should  be  the  basis  on 
which  is  determined  his  fitness  to  take  part  in 
the  various  features  of  the  camp  program. 

Athletics  for  the  Older  Boy  and  Girl. — Phys- 
ical training  means  such  mastery  and  control 
of  the  body  that  it  will  execute  the  will  and  carry 
out  the  mind's  ideals.  Wlien  a  boy  learns  to 
run,  swim,  or  play  any  organized  game  he  is  ac- 
quiring that  confidence,  independence,  and  self- 
control  which  make  for  health,  and  which  will 
stand  him  in  good  stead  in  his  future  life.  The 
increased  participation  of  girls  in  physical 
games   and   sports  argues  well,  not   only  for 

142 


EXERCISE  AND  RECREATION 

their  own  happiness,  but  for  the  welfare  of  the 
families  they  will  later  have  in  charge. 

Young  people  when  they  come  to  a  certain 
age  tend  to  assume  more  and  more  responsi- 
bility for  their  own  actions,  and  this  is  the  time 
when  they  should  begin  to  take  a  personal  in- 
terest in  their  health.  The  spur  of  "making 
the  team,"  or  the  aim  to  excel  in  classwork,  may 
be  the  means  of  first  bringing  home  to  the  young 
student  the  necessity  of  conserving  both  his 
nervous  strength  and  his  physical  powers. 

The  student  should  never  come  to  a  period  of 
study  tired  out  by  physical  exercise,  nor  should 
a  person  w^ho  is  exhausted  from  mental  effort 
turn  at  once  to  severe  physical  exertion  with- 
out rest.  There  is  a  curious  notion  that  physi- 
cal and  mental  fatigue  are  quite  separate  and 
distinct,  and  that  one  in  some  way  relieves  the 
other.  We  have  only  a  limited  amount  of 
energy,  and  if  it  is  spent  in  one  way  it  is  not 
available  in  another.  It  is  advantageous  to 
change  from  one  form  of  activity  to  the  other, 
but  if  the  point  of  fatigue  has  been  reached, 
rest  is  necessary  before  further  effort,  even  in 
a  new  direction,  will  be  really  productive. 

A  student  who  is  trying  to  excel  along  mental 
lines  should  avoid  the  strain  of  trying  to  excel 
physically  at  the  same  time,  although  he  needs 

143 


NUTRITION  AND  GROWTH  IN  CHILDREN 

regular  exercise  and  general  physical  training. 
A  boy  who  tries  to  train  for  football,  baseball, 
and  track,  one  after  the  other,  will  grow  stale 
and  excel  in  nothing  except  at  the  risk  of  per- 
manent physical  or  nervous  injury. 

All  training,  whether  mental  or  physical, 
should  stop  before  the  point  of  overfatigue. 

Health  in  Industry  and  Business. — A  thorough 
physical  examination  at  the  entrance  to  every 
form  of  organized  employment  would  prevent 
many  later  failures  and  breakdowns.  For  the 
young  person  who  starts  his  career  with  the 
handicap  of  underweight,  permanent  success  is 
unlikely  unless  he  takes  steps  to  remedy  the 
condition  promptly.  The  proper  program  is 
the  same  as  that  outlined  for  the  malnourished 
child  with  such  adjustment  as  may  be  necessary 
to  meet  the  conditions  of  his  particular  job. 

All  young  people  who  are  employed  indoors 
should  make  it  a  point  to  follow  some  outdoor 
game  or  sport  all  the  year  round,  and  the  Sat- 
urday half-holiday,  and  Sunday  as  far  as  possi- 
ble, should  be  spent  in  the  open.  A  "vacation" 
thus  taken  systematically  throughout  the  year 
will  do  more  to  promote  health  than  a  single 
break  of  a  few  weeks  or  months  annually,  with 
a  return  to  bad  habits  of  daily  living. 

The  natural  ambition  of  the  young  should  be 
144 


EXERCISE  AND  RECREATION 

encouraged.  Although  there  is  danger  in  over- 
work, there  is  also  danger  in  underwork  and  in 
the  dullness  that  comes  from  under  develop- 
ment of  one's  powers.  It  is  not  work  that  kills, 
but  overwork  complicated  by  friction,  worry, 
and  poor  hygiene.  To  offset  such  conditions 
proper  rest  and  recreation  are  a  necessity. 
Recreation  that  is  derived  from  physical  exer- 
cise is  better  than  the  passive  entertainment  of 
the  theater  or  the  movies,  or  even  of  the  bleach- 
ers at  a  ball  game. 

Indoor  exercise  consisting  of  five  or  ten  min- 
utes of  ''setting  up"  or  stretching  exercises 
daily  will  keep  the  muscles  from  becoming  soft 
and  flabby.  Unaccustomed  exercise  causes  stiff- 
ness and  lameness,  and  the  body  can  be  kept  in 
trim  only  by  steady  exercise  at  regular  intervals. 

The  extent  to  which  adults  use  exercise  and 
play  in  their  own  lives  makes  it  easier  for  the 
child  to  start  right,  and  tends  to  raise  the  stand- 
ards of  health  for  all.  Parents  who  share  in 
the  sports  and  games  of  their  children  will  come 
to  a  better  understanding  with  them  in  all  other 
matters.  It  is  fortunate  that  recreation  for  the 
adult,  which  was  formerly  considered  something 
to  be  indulged  in  quietly  or  even  secretly,  is  now 
coming  out  in  the  open  and  taking  its  part  in 
every  well  planned  health  program. 

145 


CHAPTER  XIV 

THE   PRE-SCHOOL   CHILD 

The  age  from  two  to  six  is  the  most  neglected 
period  in  the  life  of  the  child.  Knowledge 
of  infant  feeding  and  hygiene  has  become  so 
wide-spread  that  children  in  all  circumstances 
of  life  now  receive  intelligent  care  during  in- 
fancy. There  is  the  trained  nurse  to  advise 
and  instruct  the  mother  at  the  time  of  birth,  and 
the  specialist  to  be  consulted  either  at  the  clinic 
or  in  private  practice.  This  care  represents 
the  greatest  advance  of  recent  years  in  the 
science  of  medicine,  and  it  is  reflected  in  a 
steadily  diminishing  infant  death  rate.  Even 
in  so  large  a  city  as  New  York  the  work  has 
been  so  thoroughly  established  that  infant  mor- 
tality is  lower  there  than  in  the  rest  of  the  state. 
This  same  close  attention  to  the  health  of  the 
child  is  needed  throughout  the  growing  period. 

Following  infancy,  however,  measured  feed- 
ing is  gradually  discontinued,  and  there  is  a 
tendency  to  break  away  from  the  program  so 
carefully  planned  for  every  hour  of  the  day. 
By  the  time  the  child  is  two  or  three  years  old 

146 


THE  PRE-SCHOOL  CHILD 

he  is  usually  allowed  to  choose  his  own  food 
both  as  to  kind  and  quantity,  and  his  activities 
are  regulated  by  his  whim  or  the  convenience 
of  older  members  of  the  family.  Faulty  food 
and  health  habits  are  consequently  formed,  and 
there  is  too  little  attention  to  the  matter  of  sleep. 
Physical  defects  are  often  neglected  at  this  time 
in  the  belief  that  the  child  will  outgrow  them 
or  that  he  is  too  young  to  be  operated  upon. 

Yet  these  are  critical  years  in  the  matter  of 
health,  as  a  glance  at  the  mortality  statistics 
will  show.  Ninety  per  cent  of  the  cases  of 
measles  and  whooping  cough  occur  under  the 
age  of  five,  as  well  as  more  than  95  per  cent  of 
the  deaths  caused  by  these  diseases.  Almost 
the  same  is  true  of  diphtheria  and  scarlet  fever. 
More  than  50,000  cliildren  succumb  to  these  dis- 
eases each  year  in  America,  and  70  per  cent  of 
this  number  die  before  they  reach  the  age  of 
five.  One-fourth  of  all  deaths  occur  before  the 
end  of  the  fifth  year,  or  six  times  as  many  as 
in  the  next  10  years  of  life.^ 

Moreover,  it  is  not  merely  the  actual  death 
rate  of  this  period  that  is  to  be  seriously  con- 
sidered, but  the  complications  and  after-effects 
in  those  who  survive  the  contagious  diseases  of 

^  Frederick  S.  Cmm,  "Medical  Inspection  of  Schools— a 
Factor  in  Disease-Control." 

147 


NUTRITION  AND  GROWTH  IN  CHILDREN 

childhood.  In  the  case  histories  of  children 
treated  for  malnutrition,  the  source  of  this  con- 
dition is  traced  over  and  over  again  to  an  attack 
of  measles  or  whooping  cough.  Other  diseases 
to  which  the  pre-school  child  is  subject  are 
otitis,  tonsillitis,  bronchitis,  and  pneumonia. 
Since  the  malnourished  child  is  especially  sus- 
ceptible to  infection,  it  is  particularly  impor- 
tant to  guard  against  underweight  during  the 
years  when  the  child  is  least  immune  to  con- 
tagious children's  diseases.  These  infections 
with  their  complications  not  only  lower  the  re- 
sistance of  the  child,  but  retard  his  growth  in 
both  weight  and  height. 

Considering,  then,  the  five  chief  causes  of 
malnutrition  as  they  affect  the  pre-school  child, 
the  prevalence  of  physical  defects  is  nearly  as 
great  among  children  between  two  and  six  years 
old  as  in  any  other  age  group.  This  is  a  fact 
of  great  significance,  as  is  also  the  high  percent- 
age of  naso-pharyngeal  obstruction,  which  is 
the  most  frequent  cause  of  malnutrition.  Al- 
though, as  has  been  stated,  the  tonsils  do  not 
usually  become  diseased  before  the  age  of  five, 
adenoid  tissue  is  more  liable  to  cause  obstruc- 
tion while  the  nasal  cavities  are  small.  This 
mechanical  interference  with  breathing  leads  to 
congestion  in  the  naso-pharynx,  which  is  an- 

148 


THE  PRE-SCHOOL  CHILD 


Table  IV.    Average  Number  of  Physical  Defects  at 
Various  Ages 


Little    Wanderers'    Home 

Massachusetts 
General  Hospital 

Age 

Per  Cent 

of 

Total 

Group 

Average  Number 
Defects 

Per   Cent 

of 

Total 

Group 

Average 
Number  Defects 

All 
Kinds 

Naso- 
pharyn- 
geal 

All 
Kinds 

Naso- 
pharyn- 
geal 

3  and  under. 

4-0    

7-9     

10-12     

13   and   over. 
Unknown    . . . 
Entire  group. 

12 

21 
23 
18 
17 
9 
100 

5.0 
5.0 
5.1 
6.0 
4.3 
3.5 
5.2 

3.9 
2.5 
2.3 
3.3 
2.4 
1.3 
2.5 

9 
23 

30 

28 

6 

4 

100 

6.0 

6.9 
7.2 
6.9 
6.0 
6.4 
6.8 

3.6 

3.5 
3.6 
3.8 
3.0 
3.5 
3.5 

other  step  towards  infection.  Many  young  chil- 
dren have  almost  constant  naso-pharyngitis 
and  frequent  ''colds."  It  is  of  the  greatest  im- 
portance that  such  obstruction  be  removed  be- 
fore the  sinuses  are  largely  involved  or  before 
the  child  becomes  infected  with  any  of  the  con- 
tagious diseases. 

It  is  to  be  remembered  that  the  position  as 
well  as  the  size  and  amount  of  adenoid  tissue 
is  of  importance  in  causing  obstruction;  there- 
fore, the  removal  of  a  small  adenoid  may  give 
as  great  relief  as  the  excision  of  a  larger  mass 
of  tissue  situated  on  the  lateral  walls  of  the 
pharynx. 

Table  IV  gives  the  results  of  a  study  of  de- 
fects according  to  age  in  two  groups  totaling 
602  children. 

149 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Lack  of  home  control,  which  is  second  among 
the  causes  of  malnutrition  with  older  children, 
is  a  less  important  factor  in  this  group  because 
the  problem  of  control  is  simpler  during  this 
early  period  than  with  the  child  of  school  age. 
This  is  partly  due  to  the  natural  dependence  of 
the  child  on  the  mother,  and  to  her  relatively 
greater  physical  authority.  It  is  also  easier  to 
continue  or  regain  the  firm  control  established 
during  infancy  than  to  begin  anew' after  the  boy 
or  girl  has  been  independent  for  a  longer  period. 

Overfatigue  is,  however,  a  more  frequent 
cause  of  malnutrition  with  the  younger  child, 
and  is  a  source  of  greater  danger  to  growth  and 
development  than  at  a  later  period.  This  is  the 
age  when  the  child  is  especially  imaginative, 
and  when  he  reacts  quickly  to  every  new  asso- 
ciation. The  responsiveness  of  childhood  is  so 
attractive  that  it  leads  to  over-stimulation  on 
the  part  of  older  members  of  the  family,  who 
delight  in  exhibiting  the  child's  growing  ca- 
pacity. Visitors  and  even  the  chance  passerby 
manifest  an  interest  in  his  acts  and  sayings,  to 
which  he  naturally  responds  with  his  best  en- 
deavors. At  no  age  is  there  greater  risk  of 
nervous  overfatigue  than  during  these  early 
years  of  rapidly  expanding  observation  and 
experience. 

150 


THE  PRE-SCHOOL  CHILD 

Children  from  the  age  of  two  to  six  are  espe- 
cially prone  to  form  faulty  food  and  health 
habits,  as  previously  stated,  because  of  the  lack 
of  a  fixed  routine,  and  of  the  inadequate  train- 
ing and  supervision  usually  given  at  this  period. 
Irregular  eating  is  permitted,  and  the  child  is 
given  sweets  and  other  food  at  any  hour  of  the 
day  in  order  to  please  him  or  to  keep  him  occu- 
pied. Some  accidental  experience  at  this  time 
may  lead  to  an  aversion  for  certain  necessary 
foods,  which  increases  the  susceptibility  to 
rickets  and  other  deficiency  diseases.  While 
the  child  is  becoming  accustomed  to  new  foods 
it  is  of  the  utmost  importance  that  milk  and 
cereals  should  not  be  omitted  from  the  diet. 
This  is  perhaps  the  most  serious  dietary  dan- 
ger to  which  the  pre-school  child  is  subject. 

It  is  generally  recognized  that  as  little  medi- 
cine as  possible  should  be  given  during  infancy, 
but  there  is  an  increased  tendency  to  use  laxa- 
tives and  other  drugs  as  a  short-cut  after  the 
age  of  two,  instead  of  taking  the  trouble  to 
train  the  child  in  proper  health  habits.  The 
convenience  and  pleasure  of  adults  frequently 
lead  to  late  hours  for  the  child  who  is  too  young 
to  be  left  at  home  alone,  or  who  is  afraid  to  go 
to  bed  without  the  companionship  of  an  older 
person.    Too  often  a  tired  child  is  allowed  to 

151 


NUTRITION  AND  GROWTH  IN  CHILDREN 

fall  asleep  on  a  couch  in  the  living  room,  or  is 
carried  out  to  an  evening  entertainment  with- 
out any  consideration  of  its  possible  injury  to 
his  health  and  growth.  The  excitement  of  Sun- 
days and  holidays,  which  are  often  occasions 
also  for  over-indulgence  in  rich  and  sweet  foods, 
is  almost  invariably  reflected  in  the  child's 
weight  chart. 

The  effect  of  these  various  errors  in  diet  and 
hygiene  may  pass  unnoticed  for  a  considerable 
time  because  the  regular  weighing  which  has 
been  part  of  the  infant's  routine  is  no  longer 
considered  necessary.  The  nutrition  class 
therefore  meets  an  urgent  need  of  both  the  pre- 
school child  and  his  mother,  and  this  is  the  time 
when  the  nutrition  program  can  be  applied  with 
the  greatest  immediate  benefit  and  the  most  far- 
reaching  effect. 

Although  the  class  meetings  may  not  always 
appeal  to  the  child  of  this  age  to  the  same  de- 
gree that  they  do  to  the  older  boy  and  girl,  there 
is  nevertheless  sufficient  interest  in  the  weight 
chart  and  the  stars  to  hold  his  attention.  Since 
growth  is  relatively  greater  during  the  years 
from  two  to  six,  the  actual  gain  in  pounds  is 
small,  and  therefore  the  chart  can  be  made 
more  graphic  if  the  scale  is  doubled  by  allow- 
ing two  squares  for  each  pound  of  gain. 

152 


THE  PRE-SCHOOL  CHILD 

In  the  case  of  the  mothers,  the  opportunity 
for  getting  results  through  their  cooperation  is 
greater  than  at  any  other  period.  The  younger 
the  child,  the  greater  is  the  maternal  solicitude 
for  his  welfare.  It  is  not  lack  of  interest,  but 
lack  of  knowledge  on  the  part  of  the  mothers 
that  has  made  these  early  years  a  period  of  neg- 
lect. They  have  had  the  aid  of  the  milk  station 
and  the  infant  clinic  in  the  past,  and  the  nutri- 
tion class  is  welcomed  as  a  further  opportunity 
for  health  education.  The  weight  chart  is  a 
link  with  the  earlier  experience  of  the  parents 
in  considering  weight  the  standard  of  the 
child's  condition.  Even  parents  of  foreign 
birth  who  have  difficulty  in  acquiring  the  English 
language  can  follow  the  weight  line  on  the  chart 
with  understanding,  and  know  whether  the  child 
is  making  progress  towards  his  normal  stand- 
ard. 

The  requirements  as  to  mid-morning  lunches 
and  rest  periods  can  be  more  easily  carried  out 
at  this  period,  when  the  child  has  not  yet  become 
subject  to  school  routine.  This  is  a  matter  of 
considerable  consequence  in  localities  where 
nutrition  work  has  not  the  hearty  cooperation 
of  the  schools.  In  such  cases  the  older  child  is 
hampered  by  a  school  program  that  not  only 
produces   overfatigue   but   interferes  with   its 

153 


NUTRITION  AND  GROWTH  IN  CHILDREN 

effective  remedy  by  a  strict  adherence  to  the 
full  schedule. 

No  child  should  be  admitted  even  to  the  kin- 
dergarten until  every  effort  has  been  made  to 
bring  him  up  to  normal  weight.  This  can  be 
accomplished  best  through  the  nutrition  class 
for  the  pre-school  child,  and  his  weight  chart  is 
the  best  evidence  as  to  when  he  is  ready  to  take 
up  the  full  school  program.  When  the  mal- 
nourished child  is  not  given  such  care  during 
the  pre-school  period,  the  added  strain  of  school 
life  makes  it  increasingly  difficult  to  regain  the 
ground  lost,  and  he  risks  the  danger  of  falling 
farther  and  farther  below  his  normal  standard 
of  growth  and  health.  The  almost  even  per- 
centage of  malnutrition  found  up  through  the 
various  grades  indicates  that  this  retardation 
in  growth  tends  to  continue,  and  that  such  chil- 
dren remain  stunted  throughout  their  lives. 


CHAPTER  XV 


THE  OVERWEIGHT   CHILD 


Overweight  in  children  has  not  received  the 
attention  from  either  parents  or  physicians  that 
its  serious  menace  to  health  warrants.  It  has 
been  the  custom  to  think  of  it  as  a  hereditary- 
condition,  or  one  that  the  child  would  naturally 
outgrow.  Because  of  the  lack  of  complaint 
from  the  victims  themselves  and  also  the  fact 
that  overweight  is  not  accompanied  by  the  con- 
spicuous physical  defects  that  are  characteris- 
tic of  underweight,  obesity  has  been  viewed  as 
a  discomfort  rather  than  a  danger,  and  little 
has  been  done  to  standardize  either  diagnosis 
or  treatment. 

What  Constitutes  Overweight? — The  human 
being  is  a  wonderful  animal,  equal  to  a  great 
range  of  adjustment  and  adaptation.  He  seems 
to  be  capable  of  preserving  a  fair  degree  of 
health  under  conditions  of  great  excess  of  fat 
and  of  remarkable  leanness.  It  is  difficult, 
therefore,  to  draw  an  exact  line  to  separate 
these  overweight  children  from  the  normal. 
Clinical  evidence,  however,  corroborates  the  ex- 

155 


NUTRITION  AND  GROWTH  IN  CHILDREN 

perienee  of  life-insurance  companies  that  20 
per  cent  above  the  averages  now  in  use  may  be 
considered  the  limit  of  normal  weight,  and  any 
excess  should  be  investigated.  In  certain  chil- 
dren there  is  a  natural  tendency  to  excess  of 
fatty  tissue,  just  as  in  others,  to  bony  structure 
or  to  muscular  development;  but  when  the  ex- 
cess passes  beyond  20  per  cent,  we  call  the  con- 
dition obese. 

Comparison  of  Overweight  and  Underweight 
Children  with  Respect  to  Physical  Defects. — 
Practically  every  case  of  underweight  has 
physical  defects  directly  bearing  on  the  condi- 
tion, and  also  nervous  symptoms  that  are  easily 
demonstrable.  Overweight  has  no  such  appar- 
ent physical  defects.  Its  symptoms  are  shown 
in  the  tax  put  upon  the  heart  and  other  vital 
organs  by  the  extra  burden  of  weight  carried. 
From  this  condition  come  lessened  powers  of 
endurance  and  diminished  activity.  In  the 
matter  of  disposition,  the  fat  child  is  usually 
good  natured  and  amiable. 

As  a  result  of  the  physical  examination  of  a 
large  number  of  children,  we  have  found  the 
underweight  child  averages  nearly  six  defects, 
while  the  overweight  child  averages  less  than 
two.  Cases  are  common  in  which  it  is  impossi- 
ble to  find  a  single  physical  defect  in  the  over- 

156 


THE  OVERWEIGHT  CHILD 

weight  child.    Table  V  gives  the  results  of  one 
study  of  comparative  defects. 


Table  V.     Comparison  of  Defects  in  24  Ovebweiqht  and 
24  Underweight  Children 


Kind  of  Defect 

Number  of  Defects  in 
Overweight  Group 

Number  of  Defects  In 
Underweight  Group 

Obstructions  to  breathing 
Gingivitis     

29 
0 
5 
1 
1 
0 
0 
0 
0 

1 

0 
0 
0 

2 

1 
1 
2 
1 
1 
1 
1 

47 

105 
1 

Carious  teeth   

20 

Alveolar   abscess    

Cerumen  in  oar    

Otitis   media,    chronic... 
Phlyctenular  keratitis   .  .  . 
Eczema     

1 
7 
2 
1 
1 

Albuminuria    

3 

VaRinitis,    gonorrheal    .  .  . 

Syphilis,  hereditary   

Enuresis     

0 

1 
1 

Lateral   curvature    

Round  shoulders 

Adherent  prepuce  

2 
17 

2 
13 

0 

0 

Bronchitis    

0 

Tuberculosis    

0 

Infantilism      

0 

177 

In  this  study  the  overweight  children  ranged 
from  20  to  133  per  cent  above  the  average 
weight  for  their  height,  and  the  underweight 
group  was  made  up  of  an  equal  number  of  un- 
selected  children  10  per  cent  or  more  under- 
weight. It  will  be  seen  that  the  average  number 
of  defects  for  the  overweight  children  was 
under  2,  while  the  average  for  the  underweights 
was  7.3.     What  is  of  even  more  signficance, 

157 


NUTRITION  AND  GROWTH  IN  CHILDREN 

only  two  of  the  first  group  had  more  than  3 
defects,  while  only  three  of  the  underweights 
had  less  than  6.  Four  of  the  obese  children 
had  no  physical  defects,  and  six  had  only  one 
each,  while  twelve  of  the  second  group  had  8  or 
more  each. 

Danger  o£  Overweight. — Although  the  over- 
weight children  are  especially  free  from  defects 
that  interfere  with  respiration,  the  extra  bur- 
den put  upon  the  lungs  and  circulation  by  their 
condition  makes  them  less  likely  to  recover 
from  pneumonia,  or  other  acute  illness.  In  the 
case  of  infantile  paralysis  obesity  is  a  handicap 
that  often  prevents  recovery.  Joslin  states  that 
overweight  is  a  predisposition  to  diabetes. 
"The  overweight  is  at  least  twice  and  at  some 
ages  forty  times  as  liable  to  the  disease."^ 

The  body  is  constantly  trying  to  eliminate  the 
excess  food  taken.  What  cannot  be  eliminated 
is  stored  as  fat.  The  effect  of  this  condition  is 
a  tendency,  in  greater  or  less  degree,  to  toxe- 
mia, which  results  in  a  disinclination  to  physi- 
cal or  mental  exertion,  and  hinders  normal  de- 
velopment. 


^E.  P.  Joslin,  "The  Prevention  of  Diabetes  Mellitus," 
Journal  of  the  American  Medical  Association,  Vol.  76, 
No.  2,  January  8,  1921,  pp.  79-84. 

158 


THE  OVERWEIGHT  CHILD 

In  general  it  may  be  said  that  the  younger 
the  child,  the  less  is  the  danger  from  over- 
weight. 

The  Cause  of  Overweight. — The  chief  cause 
of  obesity  is  the  habitual  intake  of  more  food 
than  is  burned  up.  As  a  rule,  this  is  the  result 
of  an  appetite  for  foods  of  high  caloric  value, 
especially  fats  and  sweets.  The  fat  child,  how- 
ever, may  take  less  food  daily  than  is  eaten  by 
a  thinner  child,  and  yet  put  on  weight.  This  is 
explained  only  in  part  by  the  greater  activity 
of  the  latter.  A  more  important  factor  is  that 
such  defects  as  are  found  in  fat  children  are 
usually  those  which  do  not  interfere  with  nutri- 
tion. 

It  is  remarkable  how  general  is  the  idea  even 
among  physicians  that  the  usual  cause  of  obe- 
sity is  some  abnormality  of  the  endocrine 
glands.  Such  abnormalities  do  occur,  but  with 
the  exception  of  those  of  the  thyroid,  are  so 
rare  that  this  cause  may  be  disregarded  except 
in  large  hospital  clinics  where  such  cases  may 
be  considered  medical  curiosities.  The  use  of 
thyroid  extract  in  the  treatment  of  obesity  is  a 
short  cut  attended  with  danger  to  the  growing 
tissues  and  is  seldom,  if  ever,  necessary. 

The  Remedy  for  Overweight. — The  remedy 
for  overweight  is  measured  feeding.    The  child 

159 


NUTRITION  AND  GROWTH  IN  CHILDREN 

should  be  weighed,  and  a  careful  record,  in  cal- 
ories, should  be  kept  of  his  food  for  a  week, 
with  a  second  weighing  to  show  how  much  fuel 
the  body  is  able  to  consume  in  that  period.  A 
reduction  of  one-third  of  the  daily  average 
should  then  be  made,  which  will  afford  an  op- 
portunity for  the  burning  up  of  some  of  the 
stored  tissue.  If  the  loss  in  weight  each  week 
does  not  exceed  two  pounds,  the  child  will  feel 
better  while  the  reduction  is  going  on,  and  will 
show  a  constant  increase  in  efficiency. 

If  there  is  no  loss  of  weight  with  a  reduction 
of  one-third  the  amount  of  food  usually  taken, 
a  further  reduction  of  100  calories  per  day 
should  be  made,  until  it  is  found  what  amount 
of  food  will  bring  about  the  desired  rate  of  loss. 
The  total  amount  may  be  reduced  to  800  or  900 
calories  per  day,  if  necessary,  without  causing 
symptoms  of  starvation. 

The  character  of  the  food  habitually  taken 
should  be  changed  so  as  to  reduce  or  eliminate 
all  foods  of  high  caloric  value,  such  as  fat  meats, 
butter,  cream,  candy,  "made"  dishes,  pastry, 
and  chocolate,  and  to  substitute  in  their  place 
lean  meats,  fruits,  and  vegetables,  salads  with 
little  oil,  bran  muffins  and  bulky  foods  which 
will  satisfy  the  appetite  and  prevent  constipa- 
tion. 

160 


FlGCRE   25        AS  OVERWEIGHT   CIRF. 


Loiiisp  at  twelvp  years  was  TOO  pounds  overwoicrht.  H^r  nhvsical- 
srrowtli  examination  failed  to  disclose  a  single  defect,  nor  did  an  Xrav 
examination  of  tlie  sella  turcica,  etc..  sliow  anv  alinormalitv.  Tier  over- 
weight condition  was  due  to  fanltv  food  habits.  The  right  half  of  the 
picture  shows  the  result  of  restricting  her  diet  to  about  .'^00  calories 
per  day — a  loss  of  75  pounds  in  8'J  weeks.  An  increase  in  height  at 
the  same  time  brought  lier  into  Iietter  proportions.  Her 
progress  is  shown  graphically  in  Figure  26 


THE  OVERWEIGHT  CHILD 

Although  successful  treatment  is  essentially 
a  matter  of  diet,  physical  exercise  which  is  not 
overfatiguing  will  also  assist  the  process  of  re- 
duction. Swimming,  rowing,  walking,  and  mod- 
erate exercise  of  any  kind  should  be  encouraged, 
but  it  is  necessary  to  remember  that  many 
overweight  children  do  not  have  sufficient 
strength  for  hard  exertion,  and  have  to  train 
gradually  for  heavier  tasks. 

Influence  of  Heredity. — While  the  natural 
tendency  to  excess  of  fatty  tissue  in  certain 
children  must  be  admitted,  and  this  often  ap- 
pears as  a  family  characteristic,  overweight  is 
far  more  frequently  caused  by  habit  than  by 
heredity.  Many  children  are  allowed  to  indulge 
themselves  in  overeating  on  the  ground  that 
they  were  born  to  be  fat,  and  that  nothing  can 
save  them  from  this  condition.  A  similar  con- 
dition in  one  of  the  child's  parents  may  be  the 
direct  result  of  like  habits  uncorrected  in  youth. 
In  our  clinics  we  have  had  many  cases  of  chil- 
dren believed  to  be  destined  to  thinness  by  a 
resemblance  to  one  or  the  other  parent,  who, 
when  given  special  treatment  and  care,  go  be- 
yond normal  weight  and  actually  become  obese. 
On  the  other  hand,  the  fat  children  who  have 
followed  the  directions  here  given  show  that 
there  is  no  need  of  their  continuing  to  suffer 

161 


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This  Is  the  chart  of  Louise  whose  picture  appears  in  Figure  25.     It 
shows    that   while   she   was   losing   weight,    she   grew   in    height   at 
nearly  the  average  rate.  Illustrating  that  there  is  a  physio- 
logical force  that  malies  for  the  normal. 

162 


THE  OVERWEIGHT  CHILD 

from  overweight.  Every  child  should  be  con- 
sidered as  an  individual,  and  be  given  all  possi- 
ble aid  to  a  normal  and  healthy  development. 

Figures  25  and  26  illustrate  the  results  of 
a  faithful  reduction  in  food  during  a  period  of 
seven  months.  In  spite  of  the  marked  loss  in 
weight  there  was  nearly  the  average  increase  in 
height,  which  operated  to  reduce  the  percentage 
of  overweight  in  this  case.  Normal  growth  in 
height  during  the  period  of  treatment  tends  to 
offset  a  certain  amount  of  excess  fat,  and  to 
bring  the  body  into  better  proportions. 


CHAPTER  XVI 

QUESTIONS   COMMONLY  ASKED 

We  have  had  occasion  to  answer  thousands 
of  questions  in  our  nutrition  classes,  in  the  con- 
sultation room,  and  in  letters  from  parents. 
Wliile  these  inquiries  cover  a  wide  range  of  top- 
ics, certain  questions  are  sure  to  appear 
wherever  a  group  of  mothers  begin  to  talk  about 
malnourished  children.  From  this  experience 
the  following  representative  questions  have 
been  selected,  which  it  will  be  noticed  center 
about  the  five  principal  causes  of  malnutrition, 
namely:  physical  defects,  lack  of  home  control, 
overfatigue,  improper  diet  and  faulty  food  hab- 
its, and  faulty  health  habits. 

1.  Is  underweight  serious  in  a  child  who 
seems  healthy,  has  a  good  appetite,  and  is  as 
active  as  any  child  of  his  age? 

When  the  body  weight  is  not  sufficient  to  sus- 
tain the  height,  the  muscles  are  apt  to  show 
lack  of  tone,  and  the  nervous  system  is  almost 
invariably  unstable.  An  underweight  child  has 
less  resistance  to  disease,  and  is  less  able  to 
withstand  nervous  strain,  as  he  lacks  the  re- 

164 


COMMON  QUESTIONS 

serve  provided  by  a  normal  body  weight.  If 
his  food  habits  are  corrected,  his  activity  re- 
duced, severe  physical  exercise  omitted,  and 
rest  periods  taken  morning  and  afternoon,  it 
will  soon  be  found  that  his  weight  has  increased. 
His  general  condition  will  also  show  an  improve- 
ment similar  to  that  which  appears  after  a  long 
vacation,  and  you  will  realize  that  your  stand- 
ards of  health  for  the  child  have  been  inadequate. 

2.  At  what  age  is  it  safe  to  remove  diseased 
adenoids  and  tonsils? 

In  the  case  of  adenoids  we  advise  removal  as 
early  as  they  are  found  to  be  diseased  or  to 
cause  obstruction.  Under  the  age  of  five  their 
removal  is  usually  sufficient  to  relieve  ob- 
structed breathing.  The  tonsils  may  be  en- 
larged, but  do  not  usually  become  infected  ear- 
lier than  the  age  of  four  or  five.  They  should 
be  watched,  however,  and  if  they  become  dis- 
eased, it  is  better  to  remove  them  at  once.  The 
child  should  be  kept  in  bed  five  days  to  accom- 
plish full  recovery  and  prevent  loss  in  weight. 

3.  Are  enlarged  cervical  glands  a  sign  of 
tuberculosis? 

Enlarged  glands  are  an  indication  of  various 
infections.    The  glands  become  enlarged  in  an 

165 


NUTRITION  AND  GROWTH  IN  CHILDREN 

effort  to  resist  invading  organisms.  Enlarge- 
ment of  the  posterior  cervical  glands  may  be 
caused  by  organisms  that  come  from  the  scalp 
due  to  local  irritation,  but  enlargement  of  the 
anterior  cervical  glands  is  usually  secondary 
to  diseased  tonsils.  The  infecting  organism 
may  also  be  that  of  tuberculosis,  and  therefore 
the  condition  should  receive  prompt  attention, 
especially  in  a  debilitated  child. 

4.  Are  carious  teeth  a  serious  cause  of  mal- 
nutritionf 

Small  cavities  in  the  teeth  do  not  apparently 
affect  nutrition,  but  alveolar  abscesses  and 
large  cavities  which  affect  approximation  dis- 
turb the  digestion  and  produce  poison  products 
which  are  absorbed.  The  teeth,  therefore, 
should  be  given  the  best  possible  care,  and  even 
small  cavities  should  receive  prompt  attention 
by  a  dentist. 

5.  Is  tuberculosis  in  children  always  perma- 
nent? 

It  is  found  that  the  majority  of  children  under 
sixteen  have  had  tubercular  infection  at  one 
point  or  another,  and  although  such  infection 
is  permanent,  healing  takes  place  about  the 
tubercular  process  and  it  may  cause  no  further 
trouble.     The  greatest  safeguard  against  fur- 

166 


COMMON  QUESTIONS 

ther  extension  is  to  keep  tlie  nutrition  up  to 
normal  standards,  and  when  this  is  done  there 
is  no  reason  why  the  child  should  not  become 
strong  and  well. 

6,  Is  it  proper  to  expose  children  to  whoop- 
ing cough  and  other  infectious  diseases  in  the 
summer  time  in  order  that  they  may  not  take 
them  at  a  more  unfavorable  season? 

Children  should  never  be  exposed  to  infec- 
tious diseases  intentionally.  Whooping  cough, 
measles,  and  scarlet  fever  often  have  serious 
after  effects,  and  the  younger  the  child  the 
greater  the  danger.  Where  these  diseases  can- 
not be  avoided,  the  patients  should  be  given 
special  care  to  prevent  loss  in  weight  and  con- 
sequent malnutrition. 

7.  What  do  you  mean  by  a  "defect"? 

A  defect  is  an  abnormal  organic  physical  con- 
dition. Most  defects  fall  into  two  large  classes ; 
those  due,  first,  to  inflammatory  processes 
which  cause  malnutrition,  such  as  diseased 
adenoids  or  tonsils,  carious  teeth,  otitis,  pye- 
litis, and  the  inflammatory  conditions  caused  by 
pediculosis  and  worms;  and,  second,  those  de- 
formities that  are  a  result  of  malnutrition,  such 
as  fatigue  posture,  round  shoulders,  lateral 
curvature  and  flat  feet.    We  also  include  as  de- 

167 


NUTRITION  AND  GROWTH  IN  CHILDREN 

fects  such  nervous  disturbanoes  as  diuresis  and 
chorea. 

8.  Should  a  child  be  made  to  lie  down  when 
he  cannot  sleep? 

The  child  who  does  not  fall  asleep  naturally 
after  several  hours  of  activity  is  probably  suf- 
fering from  nervous  over-stimulation  as  a  re- 
sult of  fatigue.  This  is  an  indication  that  he 
has  special  need  of  rest.  There  may  be  cause 
of  his  failure  to  sleep  in  the  conditions  of  the 
room  as  to  light,  heat,  or  noise.  Frequently  the 
wakefulness  is  due  to  the  mistaken  notion  that 
he  will  go  to  sleep  more  quickly  if  he  is  allowed 
to  take  toys  and  books  to  bed  with  him.  He 
should  be  taught  to  lie  quietly  for  a  short  period 
and  then  gradually  lengthen  the  time.  Rest 
does  not  necessarily  mean  sleep,  but  when  a 
child  has  once  learned  to  rest  quietly  he  usually 
drops  off  to  sleep.  It  is  valuable  training  to 
acquire  in  early  life  the  habit  of  being  able  to 
turn  the  tide  of  fatigue  during  the  day  by  a  few 
minutes  of  thorough  rest. 

9.  Does  a  child  get  really  "good  sleep''  in 
the  daytime?    How  much  sleep  is  necessary? 

The  number  of  hours  a  child  may  sleep  to  ad- 
vantage varies  within  what  may  be  called  a  zone 

168 


COMMON  QUESTIONS 

of  safety.  Long  hours  of  sleep  will  not  neces- 
sarily prevent  overfatigue.  A  child  may  sleep 
14  hours  a  day,  and  yet  suffer  from  too  great 
or  too  continuous  mental  or  physical  activity 
during  the  other  10  hours.  Overfatigue  is  best 
prevented  by  the  use  of  rest  periods  during  the 
day,  which  provide  a  new  supply  of  energy 
before  the  child  has  gone  beyond  the  limit  of 
his  strength. 

People  living  in  tropical  climates  have 
learned  to  divide  their  sleeping  time  by  taking 
a  siesta  in  the  middle  of  the  day,  thus  increas- 
ing the  amount  of  time  for  other  purposes  in 
the  freshness  of  the  morning  and  the  cool  of 
the  evening. 

Because  so  many  hours  are  spent  in  sleep  it 
is  important  that  the  air  in  the  room  should 
be  as  fresh  as  that  outdoors. 

The  child  of  school  age  should  have  from  10 
to  12  hours  of  sleep  at  a  regular  time,  aside  from 
his  rest  periods. 

10.  What  does  it  mean  when  a  child  grinds 
his  teeth  in  sleep? 

This  may  be  a  sign  of  worms,  adenoid  or 
tonsil  infection,  indigestion,  overfatigue,  or 
nervous  disturbance.  Whenever  it  is  noticed, 
the  cause  should  be  sought  and  removed.    A 

169 


NUTRITION  AND  GROWTH  IN  CHILDREN 

careful  following  of  the  nutrition  program  will 
meet  the  need  in  the  case  of  any  of  these  causes 
except  worms,  for  which  special  treatment  is 
necessary. 

11.  What  is  the  test  treatment  for 
''worms'7 

In  case  intestinal  parasites  are  suspected,  a 
physician  should  be  consulted,  as  it  is  easy  to 
mistake  shreds  of  cellulose  in  the  stools  for 
thread  worms.  "When  worms  are  found,  treat- 
ment should  be  carried  out  under  a  physician's 
directions.  Do  not  trust  ''worm  cures"  or 
other  patent  medicines.  Injury  is  frequently 
caused  by  repeated  injections  and  purges. 
Treatment  should  continue  until  all  traces  of 
either  worms  or  eggs  have  failed  to  appear  for 
at  least  two  weeks.  When  treatment  is  stopped 
before  this  is  accomplished,  conditions  are  soon 
as  bad  as  ever. 

12.  TF%  do  certain  foods  disagree  with  one 
child  and  not  with  another? 

This  may  be  due  to  a  food  idiosyncrasy  which 
in  most  cases  is  gradually  outgrowm.  The 
symptoms  may  be  convulsions,  a  rash  resem- 
bling eczema,  or  throat  difficulty  similar  to  bron- 
chitis and  asthma.    The  foods  most  apt  to  dis- 

170 


COMMON  QUESTIONS 

agree  with  children  are  egg  albumen,  cow's  milk 
(rarely),  oatmeal,  nuts,  strawberries,  raw  ap- 
ples, and  shell  fish.  Proteid  tests  by  a  physi- 
cian will  determine  the  kinds  of  food  which  it 
is  necessary  to  limit  in  a  given  case. 

Children  have  varying  ability  to  digest  cer- 
tain kinds  of  food.  For  example,  butter  fat 
may  be  perfectly  digested,  but  cream  will  cause 
indigestion.  Such  variations  are  within  normal 
limits,  but  care  should  be  exercised  in  forcing 
a  child  to  take  too  much  of  any  food  for  which 
he  has  an  aversion. 

13.  Whi/  are  tea  and  coffee  injurioiisf  What 
is  the  effect  of  cocoa? 

Drugs  have  a  very  serious  effect  upon  grow- 
ing tissue.  There  appears  to  be  a  lack  in  child- 
hood of  the  immunity  that  usually  develops 
with  maturity.  Tea  and  coffee  contain  about 
two  grains  of  caffein  to  the  cup  or  glass.  Even 
Aveak  tea  or  coffee  gives  to  a  child  nearly  as 
much  of  the  drug  as  would  be  contained  in  an 
ordinary  dose. 

The  theo-bromine  in  weak  cocoa  does  not 
show  any  bad  effect,  and  a  small  amount  of 
cocoa  gives  a  flavor  to  milk  and  thus  renders  it 
palatable  to  many  children  who  would  otherwise 
have  difficulty  in  taking  as  much  milk  as  they 

171 


NUTRITION  AND  GROWTH  IN  CHILDREN 

need.  When  cocoa  is  given  for  mid-morning  and 
mid-afternoon  lunches,  it  should  be  only  slightly 
sweetened,  as  the  sugar  diminishes  the  appetite 
for  the  next  meal.  The  most  important  differ- 
ence between  cocoa  and  the  other  drinks  is  that 
there  does  not  seem  to  be  any  desire  to  increase 
its  strength,  and  children  do  not  form  a  ''cocoa 
habit." 

14.  How  can  constipation  he  cured  without 
drugs? 

The  child  should  be  trained  to  a  regular  move- 
ment of  the  bowels  at  the  same  time  every  day, 
preferably  just  after  breakfast.  A  suppository 
or  an  injection  of  an  ounce  of  liquid  petroleum 
may  be  used  to  start  the  habit.  One  or  two 
glasses  of  water  taken  before  breakfast  are 
helpful,  and  coarse  cereals,  vegetables,  and 
fruit  will  also  act  as  laxatives.  Bran  stirred 
into  the  cereal  is  beneficial,  or  cooked  bran 
eaten  with  cream  and  sugar.  Oatmeal  and 
cornmeal  bread  sweetened  with  molasses  are 
good  foods.  Prunes  and  figs  are  also  useful. 
Concentrated  foods  such  as  rich  cakes  and 
pastry  should  be  carefully  avoided. 

Constipation  is  usually  a  sjTnptom  of  indiges- 
tion; therefore,  plenty  of  time  at  meals  and 
good  food  habits  are  important.    Until  regular 

172 


COMMON  QUESTIONS 

bowel  habits  are  established  liquid  paraffin  may 
be  used,  as  it  is  not  a  drug  and  does  not  form  a 
habit.  It  should  be  given  to  the  child  in  doses 
of  two  to  four  teaspoonfuls  belore  meals  or  on 
retiring. 

These  measures  shouUl  be  sufficient,  but  if 
constipation  persists  other  causes  must  be 
looked  for,  such  as  intestinal  obstruction,  adhe- 
sions, or  sub-acute  appendicitis. 

15.  How  can  enuresis  he  cured? 

Enuresis,  or  bed-wetting,  is  not  a  disease  but 
rather  the  persistence  of  an  infantile  condition 
or  habit.  Most  children  gain  control  of  the  blad- 
der by  the  end  of  the  third  year  when  properly 
trained.  The  "wet  habit"  is  a  serious  matter 
in  any  family,  but  when  it  is  found  among  chil- 
dren for  whom  foster  homes  are  being  sought,  it 
seriously  affects  their  opportunities  for  adop- 
tion or  for  placing  in  desirable  families. 

Most  cases  can  be  cured  within  a  week  by  the 
following  treatment: 

No  liquids  or  fruit  to  be  taken  after  4  p.m. 

A  rather  light  dry  supper;  for  example,  a  cereal 
with  not  more  than  a  tablespoonful  of  milk. 

A  bland  diet;  no  tea,  coffee,  or  highly  seasoned 
foods  at  any  time,  and  no  candy  or  desserts  between 
meals. 

173 


NUTRITION  AND  GROWTH  IN  CHILDREN 

The  bladder  emptied  on  going  to  bed  and  at  inter- 
vals of  one  hour  until  midnight,  and  of  two  hours 
from  then  until  morning.  These  periods  should  be 
lengthened  one-half  hour  each  night.  An  alarm  clock 
is  useful  at  night,  and  a  chamber  should  be  placed  on 
a  rug  at  the  bedside  convenient  for  use. 

When  it  is  found  that  a  child  wets  himself  at 
a  certain  hour,  the  bladder  should  be  emptied 
half  an  hour  before  that  time  for  several  days 
until  the  habit  is  cured.  This  is  especially  apt 
to  occur  about  one  hour  after  going  to  bed. 

The  child  should  be  encouraged  by  stars  and 
other  rewards  for  every  dry  day  and  dry  night. 
He  should  not  be  punished  for  bed-wetting,  as 
it  is  involuntary  and  he  docs  not  know  when  the 
act  occurs.  Encourage  him  to  be  alert  to  feel 
the  need  of  emptying  his  bladder.  Guard 
against  overfatigue  and  excitement.  Be  insist- 
ent upon  the  mid-morning  and  mid-afternoon 
rest  periods.  Drugs  are  of  little  or  no  use. 
Patience  and  persistence  will  win  out  in  prac- 
tically every  case. 

16.  If  a  malnourished  child  is  brought  up  to 
standard,  does  he  stay  up  to  standard? 

In  order  to  bring  a  child  up  to  normal  weight 
it  is  necessary  to  find  the  cause  of  his  poor 
nutrition,  to  remove  the  cause,  and  to  teach  him 

174 


COMMON  QUESTIONS 

good  food  and  health  habits.  Therefore,  after 
he  gets  well  the  knowledge  and  habits  thus  ac- 
quired  serve  to  keep  him  so.  Relapses  do  occur 
due  to  causes  over  which  neither  children  nor 
parents  have  control;  but  otherwise  the  mal- 
nourished boy  or  girl's  chances  of  keeping  well 
are  equal  and  possibly  better  than  those  of  a 
child  who  has  never  been  malnourished. 

17.  7s  it  safe  to  omit  milk  from  the  diet  of  a 
growing  child? 

No.  Milk  is  the  only  complete  food  for  hu- 
man beings,  and  is  the  greatest  safeguard 
against  any  deficiency  in  either  the  character 
or  amount  of  the  diet.  The  well  child  should 
have  a  pint  of  milk  every  day,  and  the  under- 
nourished child  should  take  a  quart  in  one  form 
or  another.  At  least  a  pint  of  milk  should  be 
taken  daily  all  through  the  growing  period,  that 
is,  until  maturity.  Some  of  the  most  pro- 
nounced and  serious  cases  of  malnutrition  are 
found  among  those  children  who  have  omitted 
milk  from  their  diet. 

18.  What  are  vitamins,  and  in  ivhat  foods 
do  they  occur? 

The  term  ** vitamins"  is  used  to  designate 
certain  accessory  food  products  necessary  for 

175 


NUTRITION  AND  GROWTH  IN  CHILDREN 

nonnal  growth.  These  accessory  factors  are  of 
three  kinds. 

''Fat-soluble  A"  is  kno^vn  as  the  antirachitic 
factor,  and  occurs  mainly  in:  (a)  certain  fats 
of  animal  origin,  and  (5)  in  green  leaves.  The 
most  notable  deposits  are  in  cream,  butter,  beef 
fat,  cod  liver  oil,  and  egg  yolk.  The  leafy  vege- 
tables that  contain  it  are  chiefly  celery,  lettuce, 
onions,  cauliflower,  cabbage,  Brussels  sprouts, 
spinach,  Swiss  chard,  and  beet  tops. 

"Water-soluble  B,"  known  as  the  anti- 
neuritic  (beri-beri)  factor,  is  found  in  almost 
all  natural  food  products,  its  principal  source 
being  the  seeds  of  plants  and  eggs  of  animals. 
Yeast  cells  are  a  rich  source,  also  the  germ  and 
outside  layer  (the  bran)  of  cereals,  but  it  is 
absent  in  polished  rice  and  white  wheat  flour. 

The  antiscorbutic  factor  occurs  in  fresh  vege- 
tables, and  largely  in  lemons,  oranges,  raspber- 
ries, and  tomatoes.  Potatoes,  milk,  and  meat 
possess  a  definite  but  low  antiscorbutic  value. 

The  following  table,  taken  from  that  prepared 
by  the  British  committee  appointed  by  the 
Medical  Eesearch  Committee  and  the  Lister  In- 
stitute for  use  during  the  war  in  famine-stricken 
districts,  shows  the  distribution  of  these  acces- 
sory factors  in  the  commoner  foods. 


176 


COMMON  QUESTIONS 


Table  VI. 


DlSTBIBUTIOX    OF   THE   THREE   ACCESSOBT   FACTORS 

IN  THE  Commoner  Foodstuffs  * 


Classes   of   Foodstuff 


Fats  and  oils: 

Butter 

Cream    

Cod-liver   oil    

Beef  fat  or  suet   

Peanut  butter  and  nut 
butter    

Margarine  from  beef  fat 

Margarine  from  vege- 
table fats  or  lard. . . 

Meat,  fish,  etc.: 

Loan  meat  (beef,  mut- 
ton, etc.)    

Liver    

Kidneys    

Heart     

Fish,  white  (cod,  had- 
dock, etc.)    

Fish,  fat  (salmon,  her- 
ring etc.)    

Fish,  roe 

Tinned  meats 

Milk,  cheese,  etc.: 

Milk,  cows',  whole,  raw 
Milk,  cows',  skim,  raw 
Milk,  cows',  whole,  dried 
Milk.       cows',       whole, 

boiled    

Milk,  condensed,  sweet- 
ened      

Cheese,  whole  milk   . 
Cheese,  skim  milk  . . 

Eggs: 

Fresh     

Dried     


Fat- 
Soluble  A 


Antirachitic 
Factor 


-f  4-  + 
+  + 
+  +  + 

+ 
See  note  t 


+ 

+  + 
+  + 
+  + 


+  + 
+ 


+  + 
0 
less  than-h  -f 

undetermlned 

+ 
+ 


+  + 
+  + 


Water- 
Soluble  B 


Antineuritic 
Factor 


+ 

+  + 
+ 
+ 

very  slight 
if  any 

very  slight 
if  any 
+  + 
very  slight 


+  t  + 
H-  +  + 


Antiscorbutic 
Factor 


+ 
+ 
less  than  + 

less  than  + 


70 
70 


•  Hess  considers  this  list  too  restricted,  and  emphasizes  the 
value  of  potatoes,  and  also  of  canned  tomatoes,  which  his  experi- 
ments show  are  rich  in  the  antiscorbutic  factor.  I'reserving  does 
not  necessarily  injure  the  vitamins  provided  the  foods  are  fresh 
when  canned.  Powdered  or  canned  milk  may  prove  of  great  value 
where  a  good  supply  of  fresh  milk  cannot  be  obtained. 

t  Value  In  proportion  to  amount  of  animal  fat  contained. 


177 


NUTRITION  AND  GROWTH  IN  CHILDREN 


Table  VI.     Distrdjution  of  the  Three  Accessory  Factors 
IN  THE  Commoner  Foodstuffs* — Continued 


Classes  of  Foodstuff 


Cereals,  pulses,  etc.: 

Wheat.  maize,  rice, 
whole     

Wheat,  maize,  germ   . . 

Wheat,  maize,  bran   .  .  . 

White  wheaten  flour 
pure  cornflower,  pol 
ished  rice,  etc 

Dried  peas,  lentils,  etc. 

Veyetailes  and  fruits: 
Cabbage,  fresh,  raw 
Cabbage,   fresh,   cooked 

Lettuce     

Spinach     

Carrots,    fresh,    raw. 

Carrots,  dried    

Potatoes,  cooked  . . . 
Tomatoes,  canned   . , 
Lemon  juice,  fresh   . 
Lemon  juice,  preserved 
Orange  juice,  fresh  . 

Apples     

Bananas    

Nuts    


Miscellaneous: 

Yeast,  dried 

Yeast,  extract  and 
Yeast,  autolyzed    . . 


Fat- 
Soluble  A 


Antirachitic 
Factor 


+ 

+  + 
0 


+  + 


+  + 
+  + 
+ 
very  slight 


Water- 
Soluble  B 


Antiueuritic 
Factor 


+  +  + 

+  + 


0 

+  + 


+ 
+  + 


+  +  + 
+  +  + 


Antiscorbutic 
Factor 


0 
0 

+  +  + 
+ 
+  + 

+ 

+ 

+  + 
+  +  + 
+  + 
+  +  + 
+ 
very  slight 
+  + 


A  glance  at  this  table  will  show  that  the  wide 
distribution  of  these  elements  clearly  indicates 
their  liberal  use  in  the  average  American  diet. 
McCollum  says:^  ''It  is  now  well  demonstrated 
that  with  the  diets  employed  in  Europe  and 
A.merica  there  is  no  such  thing  as  a  'vitamin' 

1  E.  V.  McCollum,  "The  Newer  Knowledge  of  Nutrition," 
p.  138. 

178 


COMMON  QUESTIONS 

problem  other  than  that  of  securing  an  adequate 
amount  of  the  substance,  Fat-soluble  A."  He 
accordingly  recommends  milk  and  the  leafy 
vegetables  as  "protective  foods,"  including 
eggs  in  the  same  class. 

In  our  nutrition  classes  at  least  a  pint  of  milk 
a  day  is  prescribed  for  every  child,  and  when 
the  diet  lists  have  been  checked  and  corrected 
according  to  the  methods  described,  I  have 
never  known  a  case  of  malnutrition  that  could 
properly  be  diagnosed  as  "lack  of  vitamins." 


PART  III 

A  NUTRITION  PROGRAM 
FOR  THE  COMMUNITY 


CHAPTER  XVII 

THE   NUTRITION    CLASS 

Although  many  features  of  our  nutrition 
program  can  be  applied  with  excellent  results 
in  the  care  of  the  individual  child,  a  well  organ- 
ized nutrition  class  is  the  most  effective  agency 
in  the  treatment  of  malnutrition.  This  is  true 
in  the  case  of  the  rich  and  the  well-to-do  as  well 
as  among  the  poor,  for  children  are  alike  in  their 
response  to  the  stimulus  of  the  class  and  the 
spirit  of  competition. 

The  class  method  is  based  on  the  principles 
of  group  association  and  visual  instruction. 
Children  are  quick  to  imitate,  and  to  learn 
from  one  another.  They  recognize  and  respect 
"good  form"  in  any  group  to  w^hich  they  may 
belong,  and  the  business  of  getting  well  assumes 
a  new  importance  in  their  minds  when  they  see 
it  as  the  aim  and  purpose  of  their  associates. 
The  rising  line  of  the  weight  chart  and  the  im- 
proved appearance  of  those  who  gain  teach  a 
lesson  that  is  clear  to  all. 

The  child's  own  interest  is  so  aroused  by  the 
chart's  record  of  his  progress  that  on  several 

183 


NUTRITION  AND  GROWTH  IN  CHILDREN 

occasions  I  have  known  children  to  burst  into 
tears  when  they  failed  to  gain.  Often,  when  the 
weather  is  so  severe  that  scarcely  a  patient  ap- 
pears in  the  other  divisions  of  the  hospital,  the 
nutrition  class  registers  full  attendance. 

Class  Organization. — The  simple  procedure 
of  weighing  and  measuring  forms  the  basis  of 
selection.  Classes  of  not  more  than  20  children 
each  are  formed  from  those  whose  weight  is 
seven  or  more  per  cent  below  the  average.  Each 
child  is  then  given  thorough  physical,  mental, 
and  social  examinations,  as  previously  de- 
scribed, and  receives  such  advice  and  instruc- 
tion as  his  condition  requires.  The  object  of 
the  class  is  to  check  up  the  results  of  the  in- 
structions given,  and  to  make  further  recom- 
mendations as  they  may  be  needed. 

A  weight  chart  is  made  out  for  each  child, 
with  his  name,  age,  height,  and  weight  at  the 
top,  and  a  line  showing  the  average  weight  for 
his  height.  Since  a  normal  increase  in  both 
weight  and  height  is  to  be  expected  throughout 
the  growing  period,  this  average  weight  line 
does  not  represent  a  fixed  number  of  pounds, 
but  is  a  curve  allowing  for  an  expected  increase 
of  from  three  to  thirteen  pounds  per  year,  ac- 
cording to  the  age  of  the  child.  His  actual 
weight  line  is  made  by  connecting  the  dots  rep- 

184 


Figure  27.     the  case  of  Dorothea,  before  treatment 


Dorothea,  afred  cloven,  hecamo  tired  on  slislit  exertion,  so  tired  that  It 
took  her  nearly  an  hour  to  dress  in  the  morninsr.  She  would  sit  and 
dream,  rarely  smiled,  and  her  face  looked  distressed.  She  passed  the 
school  medical  inspection,  hut  was  iiiven  a  tonic  by  her  family 
physician.  The  hospital  diajinosls  was  "No  disease."  The  nutrition 
diai^nosis  was  :  underweight  '_'!  per  cent  :  naso-pharynfTPal  obstruction  : 
cervical  adenitis ;  carious  teeth  :  spinal  curvature ;  fatigue  posture. 
Nutrition  treatment  was  begun  with  the  result 
shown   in    Figure   28. 


THE  NUTRITION  CLASS 

resenting  his  first  weight  and  the  subseqi^ent 
weekly  weighings. 


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jcjfcveu        _|       __       

FiGUBE   28.      THE   CASE  OF  DOROTHEA 

After  the  spcond  welRhinR  her  mother  was  In  the  hospital  for  11 
weeks,  but  Dorothea  continued  by  herself  to  follow  all  directions, 
gaining  at  the  rate  of  half  a  pound  a  week.  This  was  increased 
to  over  a  pound  a  week  when  she  returned  to  the  class,  but  reduced 
to  half  a  pound  again  at  a  eummer  camp  which  did  not  supply 
mld-mornlng  and  afternoon  lunches.  Her  total  gain 
was  24^  pounds  in  .^6  weeks. 


"When  the  actual  weight  line  reaches  the  aver- 
age weight  line  a  new  average  weight  must  be 

185 


NUTRITION  AND  GROWTH  IN  CHILDREN 

computed  on  the  basis  of  the  actual  height  of 
the  child  at  this  time,  in  order  to  allow  for  the 
probable  growth  in  height  while  he  has  been  in 
the  class.  It  is  only  when  the  child  attains  this 
new  weight  that  he  is  considered  ready  for 
''graduation." 

A  quiet  room  large  enough  to  accommodate 
about  fifty  persons  should  be  provided  for  the 
nutrition  class,  where  it  will  be  free  from  inter- 
ruption. The  class  meets  once  a  week  at  a 
regular  hour,  and  the  children  come  to  the  class- 
room accompanied  by  their  parents.  No  child 
should  be  admitted  regularly  to  the  class  except 
at  the  request  of  his  parents,  because  their  co- 
operation and  interest  are  essential  factors  in 
successful  treatment. 

Class  Procedure. — As  the  children  arrive  they 
are  weighed  by  the  nutrition  worker,  and  their 
weight  recorded  on  the  charts.  Each  child 
brings  a  48-hour  diet  list,  which  is  checked  up 
by  the  nutrition  worker  or  her  assistants,  not 
only  with  reference  to  its  total  food  value,  but 
also  for  the  kinds  of  food  taken,  and  especially 
to  note  whether  it  contains  in  sufficient  amount 
milk,  cereal,  and  other  essential  foods.  The 
average  number  of  calories  is  recorded  on  the 
weight  chart,  whore  it  often  affords  significant 
comparison  with  the  rise  or  fall  of  the  weight 

186 


Figure  29.    tiie  case  of  Dorothea,  after  treatment 


Notice  the  transformation  ia  hoth  mental  and  physical  condition  fol- 
lowing Itie  increase  in  weiglit  s-liowu  in  Figure  "JS.  Dorothea's  mother 
sa.vs.  "Her  whole  disposition  lias  (hanged,  she  laughs,  and  is  cheerful 
and  happy."  She  overcame  lier  finicky  likes  and  dislikes  and  faithfully 
carried  out  the  directions  '-'iven  because  she  was  anxious 
to  become  well  and  strong. 


THE  NUTRITION  CLASS 

Ime.  The  nutrition  worker  also  questions  the 
child  in  regard  to  his  activities  during  the  pre- 
ceding week,  and  seeks  to  find  the  cause  in  case 
of  failure  to  gain.  Notes  of  her  findings  are 
added  to  the  child's  record  for  the  doctor's  in- 
formation. 

A  blue  star  is  affixed  to  the  weight  chart  to 
indicate  that  rest  periods  have  been  faithfully 
taken  during  the  week,  and  a  red  star  provides 
a  similar  record  in  regard  to  lunches.  A  green 
star  may  be  used  to  record  the  attendance  of 
one  or  both  parents.  This  encourages  regular 
attendance  on  the  part  of  the  parents,  and  may 
be  of  interest  in  showing  that  the  best  gains  are 
made  by  those  children  whose  parents  are  inter- 
ested enough  to  come  to  the  class  regularly. 

The  charts  are  tlien  hung  on  the  wall  in  the 
order  of  the  gains  made,  and  the  children  are 
seated  in  the  same  order  with  their  parents  be- 
hind them,  all  facing  the  charts.  A  gold  star 
is  added  to  the  chart  of  the  child  who  has  gained 
the  most  during  the  week  and  is  sitting  in  the 
place  of  honor  at  the  head  of  the  class. 

These  preliminaries  are  completed  before  the 
stated  time  for  the  doctor's  arrival,  and  he  is 
thus  enabled  to  see  at  a  glance  the  results  ac- 
complished during  the  week.  Much  of  the  in- 
struction needed  can  be  given  in  general  advice 

187 


NUTRITION  AND  GROWTH  IN  CHILDREN 

to  the  whole  group,  and  individual  recommenda- 
tions based  on  the  record  of  the  charts  will  be 
useful  to  all.  Many  a  mother  comes  to  see  more 
quickly  what  should  be  done  for  her  own  child 
when  its  effects  are  pointed  out  in  the  case  of 
another  boy  or  girl. 

There  is  great  teaching  value  in  comparing 
the  child  at  the  head  of  the  class  with  one  who 
has  not  gained,  and  explaining  the  reason  for 
the  results  in  each  case.  The  force  of  public 
opinion  in  the  class  group  can  in  this  way  be 
made  a  powerful  ally  in  removing  such  simple 
causes  of  failure  as  the  neglect  of  rest  periods 
or  lunches,  prejudice  against  open  windows, 
and  overfatigue  arising  from  late  hours  or  un- 
necessary tasks.  Care  must  be  taken,  however, 
not  to  discuss  openly  matters  about  which  either 
parent  or  child  is  rightly  sensitive. 

Food  and  Rest. — During  the  period  of  treat- 
ment in  the  nutrition  class  the  child  should  be 
placed  in  an  open-air,  or  at  least  an  open-win- 
dow, class,  and  school  pressure  should  be  re- 
duced. Most  children  need  only  sufficient  addi- 
tional time  for  a  lunch  and  rest  period  at  10 :  30 ; 
others  will  work  to  best  advantage  on  a  half- 
day  schedule;  a  few  need  to  be  limited  to  two 
hours  a  day;  while  in  certain  cases  the  child 
cannot  safely  attend  school  at  all  for  a  time. 

188 


C    «.    "" 


THE  NUTRITION  CLASS 

One  rest  period  of  at  least  half  an  hour 
should  be  taken  before  the  midday  meal,  and 
in  the  middle  of  the  afternoon  a  longer  rest,  in 
order  to  save  the  child  from  overfatigue.  The 
rest  periods  should  be  taken  as  described  in 
Chapter  IX. 

Mid-morning  and  mid-afternoon  lunches  are 
recommended  for  all  undernourished  children. 

In  addition  to  the  general  advice  given  to  all, 
both  the  physician  and  the  nutrition  worker  en- 
deavor to  discover  every  obstacle  to  each  child's 
progress,  and  recommend  such  changes  as  the 
needs  of  the  individual  require.  The  nutrition 
worker  visits  the  home  to  assist  the  parents  in 
planning  for  the  essentials  of  health,  and  to  see 
that  recommendations  have  been  understood 
and  carried  out. 

The  special  work  of  the  physician  and  of  the 
nutrition  worker  in  connection  with  the  class  is 
discussed  in  the  chapters  following. 

Results  Secured. — Successful  treatment  hi 
the  majority  of  cases  is  both  easy  and  sure,  pro. 
vided  either  the  physician,  the  nutrition  worker, 
or  the  teacher  has  the  ability  to  create  the 
vision  of  health  in  the  child's  imagination,  and 
thus  secure  his  complete  cooperation.  Wliere 
there  is,  in  addition,  the  hearty  cooperation  of 
the  home  and  the  school,  the  child  should  reach 

189 


NUTRITION  AND  GROWTH  IN  CHILDREN 

his  normal  standard  of  weight  in  10  or  12  weeks. 
It  is  recognized  that  the  nutrition  program 
demands  from  the  child  a  self-denial  and  stead- 
fastness of  purpose  to  which  he  has  not  been 


NUTRITION    CLASS 


T 


HIS  IS  TO  CERTIFY  THAT 


CViQvle.s  CU 


ilSJL- 


HAS  ATTAINED  THE  REQUIRED 
STANDARD  OF  HEALTH  AND 
WEIGHT  OFtSr>..v.»wriYer^.o.,POUNDS 


SIG 


NED    ^^I^VT^  C^^'^^l!.i..l.4n^  P^.  -3 


,-t 


DATE      -l^v^.iQV^    ,^|V/9^Q 


FiGLTJE   31.      NUTRITION    CLASS   DIPLOMA 

This  certificate  is  given  when  tbe  cliild  reaches  the  average  weight 

for  his  height.  It  ts  highly  prized  by  the  "graduates"  as  a 

recognition  of   their  own  efforts  to  got  well. 


accustomed.  For  this  reason  the  matter  of 
"graduation"  from  the  class  is  made  something 
of  a  ceremony,  and  ho  is  made  to  feel  that  the 
certificate  given  is  a  well-earned  diploma. 

In  the  early  stages  of  this  work  we  considered 
we  were  getting  good  results  when  we  were  able 

190 


THE  NUTRITION  CLASS 

to  double  the  average  rate  of  gain  as  shown  by 
the  tables.  We  now  expect  an  average  increase 
of  300  to  400  per  cent,  and  have  class  records 
showing  a  group  gain  of  1,400  per  cent  of  the 
expected  rate  of  increase.  These  results,  con- 
trasting with  the  published  reports  ^  of  gains 
made  in  diet  classes,  school-lunch  campaigns, 
and  other  partial  efforts  to  combat  malnutri- 
tion, justify  the  comprehensive  program  of  our 
nutrition  classes,  and  emphasize  the  importance 
of  the  medical  foundation  of  the  work. 

Summary. — The  class  method  in  the  treat- 
ment of  malnutrition  has  many  advantages, 
which  may  be  summarized  as  follows :  It 

Economizes  the  time  of  all  concerned  by  bringing  the 
parents  to  the  class,  and  thus  minimizing  the 
necessity  for  home  visits ; 

Secures  the  cooperation  of  the  parents — a  vital  factor 
in  making  results  permanent ; 

^  There  was  a  gain  of  170  per  cent  in  an  experiment  con- 
ducted by  Teachers  College,  Columbia  University.  (Mary 
S.  Rose  and  Gertrude  G.  Mudge.  "A  Nutrition  Class  in  Co- 
operation with  a  Summer  Play  School,"  Journal  of  Home 
Economics,  February,  1920,  Vol.  12,  No.  2.) 

The  gain  was  125  per  cent  in  an  experiment  conducted 
by  the  Hampden  County  Improvement  League,  Chicopee 
Falls,  Massachusetts.  (Minnie  Price,  "School  Lunches  and 
Educational  Work  to  Overcome  Undernourishment." 
Massachusetts  Department  of  Health,  The  Common- 
health,  July-August,  1920,  Vol.  7,  No.  4,  pp.  262-267.) 

191 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Pools  the  experience  of  all  families  for  the  benefit  of 
each; 

Favors  study  and  correction  of  home  difficulties  by 
contact  with  parents  under  friendly  circum- 
stances ; 

Introduces  a  healthy  form  of  competition ; 

Utilizes  the  approval  of  companions  to  influence  the 
child  to  follow  directions; 

Visualizes  the  essentials  of  health — an  effective 
method  in  health  education ; 

Bemoves  prejudices  and  fears  through  knowledge  of 
results  obtained,  and  convinces  in  a  moment  when 
hours  spent  in  argument  have  failed; 

Overcomes  obstacles  too  great  for  the  authority  of 
the  parent  and  for  the  undeveloped  reason  of 
the  child,  which  yield  in  a  surprising  manner 
to  the  interest  developed  in  the  class ; 

Provides  a  program  whereby  children  can  be  made 
well  in  their  own  homes  without  adding  to  the 
family  budget ; 

FurnisJies  a  basis  for  cooperation  on  the  part  of  edu- 
cational, medical,  and  all  child-helping  organiza- 
tions in  a  practical  community  health  program. 


CHAPTER  XVIII 

THE   NUTRITION   WORKEB 

The  successful  nutrition  worker  must  have 
the  following  qualifications : 

1.  Executive  ability  for  organization  and  adminis- 
tration 

2.  Genuine    interest    in    children    and    ability    to 
teach 

3.  Practical    experience   in    a   children's   medical 
clinic 

4.  Training  in  the  principles  of  nutrition  work,  in 
chart-making,  and  the  keeping  of  records 

5.  Practical    experience    in    conducting   nutrition 
classes 

It  is  her  chief  duty  to  see  that  each  child  who 
comes  under  her  care  has  the  essentials  of 
health.  In  order  to  accomplish  this  she  must 
coordinate  the  efforts  of  the  parents,  the  phy- 
sician, the  teacher,  and  the  child  himself. 

Her  first  contact  with  the  parents  comes  at 
the  time  of  the  weighing  and  measuring,  and 
she  should  use  this  opportunity  to  help  them 
understand  the  significance  of  underweight.  At 
the  first  class  meeting  she  has  a  further  oppor- 

193 


NUTRITION  AND  GROWTH  IN  CHILDREN 

tunity  to  inter-e^t  them  in  tlieir  child's  coudition 
by  means  of  the  weight  chart  and  by  explaining 
the  need  of  the  physical-growth  examination. 

When  the  class  is  definitely  organized,  she  is 
no  longer  dealing  merely  with  a  single  family 
unit,  but  has  the  larger  social  problem  of  cre- 
ating a  class  spirit  with  its  alternating  influ- 
ences of  mutual  aid  and  competition.  She  must 
interest  the  physician  in  the  class  as  a  group, 
and  help  him  become  identified  with  its  varied 
problems. 

Adjustment  of  the  daily  programs  should  be 
made  at  once  and  steps  taken  for  the  removal  of 
defects  that  all  children  may  become  "free  to 
gain"  as  soon  as  possible. 

Everything  should  be  planned  to  lead  directly 
to  the  chief  object  in  view — ^bringing  the  chil- 
dren up  to  the  normal  weight  line.  In  the  ar- 
rangement and  equipment  of  the  classroom  con- 
sideration must  be  given  not  only  to  the  needs 
of  the  children  and  the  convenience  of  the  phy- 
sician, but  also  to  the  problems  of  the  school 
or  hospital  in  which  the  class  is  conducted. 
Foresight  in  planning  the  details  of  the  work 
will  save  time  for  the  physician,  the  parents, 
and  all  concerned. 

The  nutrition  worker  arranges  to  have  the 
physical-growth  examination  made  as  promptly 

194 


THE  NUTRITION  WORKER 

as  possible.  Shie  takes  the  dictation  of  the  ex- 
amining physician  that  she  may  know  exactly 
what  defects  are  found.  The  parents  should 
be  made  to  see  that  she  understands  every  re- 
mark made  by  the  physician  so  that  later  she 
will  be  able  to  interpret  authoritatively  any- 
thing that  may  not  be  clear  to  them.  In  these 
and  many  other  ways  she  must  seek  to  gain  their 
interest  and  confidence. 

In  the  removal  of  physical  defects  brought 
out  by  the  examination  many  difficulties  are  en- 
countered. School,  home,  and  clinic  schedules 
must  be  brought  into  harmony  that  the  recom- 
mendations of  the  physician  may  be  carried 
out  without  delay.  The  worker's  records  must 
show  clearly  what  has  been  accomplished  so 
that  the  physician  will  have  an  intelligent  un- 
derstanding of  each  case  at  the  weekly  meeting 
of  the  class. 

The  Nutrition  Worker  and  the  Physician. — 
The  class  should  meet  at  least  half  an  hour  in 
advance  of  the  arrival  of  the  physician.  The 
nutrition  worker  assumes  all  responsibility  for 
making  and  keeping  the  w^eight  charts,  check- 
ing the  diet  lists,  and  attending  to  the  class 
records.  It  is  only  by  adequate  preparation  on 
her  part  that  the  physician  is  able  to  conduct 
the  class  in  the  short  space  of  half  an  hour. 

195 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Upon  tht  thoroughness  and  accuracy  of  the  in- 
formation that  she  supplies  will  largely  depend 
the  instructions  that  he  gives  for  the  ensuing 
week's  program. 

No  part  of  her  work  calls  for  more  judgment 
and  tact  than  her  relations  with  the  physician. 
Not  only  must  she  assist  in  carrying  out  his 
recommendations,  but  when  this  has  been  done 
and  the  child  still  fails  to  gain,  she  must  put 
him  on  his  mettle  to  look  deeper  into  the  cause. 
Instead  of  being  satisfied  with  the  75  or  80  per 
cent  of  the  class  who  are  making  the  desired 
progress,  she  must  direct  special  attention  to 
every  child  who  fails  to  gain,  so  that  the  phy- 
sician will  feel  the  challenge  and  devote  special 
attention  to  these  problems. 

Individuals  will  be  found  who  require  a  long 
period  of  observation  and  study  by  both  nutri- 
tion worker  and  physician  before  a  definite 
diagnosis  can  be  made.  In  one  of  our  classes 
a  boy  was  under  observation  for  a  year  and  a 
half  before  his  trouble,  cardiospasm,  was  dis- 
covered. The  cause  must  be  found  in  every 
instance  before  recovery  can  be  expected. 

Visitors. — Although  visitors  should  be  wel- 
comed, they  should  not  be  allowed  to  interrupt 
the  class  exercise.  The  best  service  that  can  be 
rendered  to  a  serious  inquirer  is  a  convincing 

196 


THE  NUTRITION  WORKER 

demonstration  of  what  can  be  accomplished  in 
a  class  period.  The  nutrition  worker  should 
not  allow  herself  to  be  diverted  by  "the  gal- 
lery," but  may  explain  the  work  in  detail  to 
those  who  are  willing  to  remain  after  the  class 
is  dismissed. 

A  Social  Diagnostician. — The  nutrition  worker 
is  so  closely  concerned  in  the  social  examina- 
tion that  she  may  be  called  a  social  diagnos- 
tician. With  the  exception  of  physical  defects, 
the  chief  causes  of  malnutrition  have  their  roots 
in  the  social  conditions  that  surround  the  child. 
It  is  the  business  of  the  nutrition  worker  first 
to  discover,  and  then  by  her  teaching  to  en- 
deavor to  remove,  lack  of  home  control,  over- 
fatigue, and  faulty  food  and  health  habits.  She 
must  become  the  focus  of  all  the  social  forces 
affecting  the  welfare  of  the  child,  conferring 
with  parent,  teacher,  clergyman,  or  other  person 
in  authority  in  any  particular  case.  She  is  the 
intermediary  between  the  physician  and  the 
parents,  and  must  represent  his  authority  both 
in  class  conferences  and  home  visits. 

Previous  training  and  experience  in  a  special 
field  may  make  it  difficult  for  the  nutrition 
worker  to  see  the  whole  problem  without  preju- 
dice in  favor  of  the  single  factor  with  which  she 
is  most  familiar.    This  tendency  is  most  com- 

197 


NUTRITION  AND  GROWTH  IN  CHILDREN 

mon  with  reference  to  diet.  After  repeated 
demonstrations  to  the  contrary,  many  workers 
still  fail  to  realize  that  while  improper  diet  is 
a  significant  item,  it  is  not  the  first  or  chief 
cause  of  malnutrition,  but  actually  fourth  in  the 
list,  and  shares  even  this  place  with  faulty  food 
habits. 

Home  Visits. — When  the  nutrition  class  is 
properly  organized,  the  necessity  for  home  visit- 
ing is  reduced  to  a  minimum.  We  have  found 
one  nutrition  worker  able  to  care  for  more  chil- 
dren by  the  class  method  than  would  usually  be 
assigned  to  three  or  four  social  workers  where 
home  visiting  is  the  chief  feature  of  the  pro- 
gram. This  is  accomplished  by  group  teaching 
when  the  class  is  in  session,  and  by  individual 
conferences  with  the  mothers  before  and  after 
the  class.  When  instruction  is  made  graphic 
by  the  weight  chart  and  results  are  apparent 
in  the  case  of  other  children,  the  mothers  be- 
come thoroughly  convinced.  Nevertheless,  a 
certain  amount  of  home  visiting  is  not  only 
necessary  but  desirable. 

The  nutrition  worker  should  go  into  the  home 
in  the  same  spirit  in  which  the  doctor  makes  his 
visit.  It  is  recognized  that  the  physician's  call 
is  for  the  definite  purpose  of  removing  illness 
and  getting  the  patient  well.    He  allows  nothing 

198 


THE  NUTRITION  WORKER 

to  divert  him  from  this  purpose,  aiid  never  be- 
trays the  family's  confidence.  The  nutrition 
worker  must  observe  the  same  scrupulous  re- 
gard for  the  dignity  of  the  family  and  her  own 
professional  standing. 

Where  she  has  won  the  full  confidence  of  the 
parents  in  the  class  conferences,  she  can  usu- 
ally make  her  visit  to  the  home  the  result  of  a 
direct  invitation.  Her  inquiries  here  should  be 
confined  to  the  definite  business  which  brought 
her  to  the  home,  and  center  about  the  essentials 
of  health  for  the  particular  child  under  her  care. 
Hygienic  policing  is  no  part  of  her  work.  She 
may  incidentally  observe  a  case  of  infectious 
disease  that  calls  for  control  by  the  Department 
of  Health,  or  a  matter  that  requires  the  atten- 
tion of  the  Society  for  the  Prevention  of  Cruelty 
to  Children;  but  she  must  stick  to  her  job,  and 
refer  these  cases  to  the  organizations  that  have 
been  established  to  meet  such  needs. 

As  nutrition  work  develops,  the  need  for 
visits  to  the  homes  of  the  rich  is  increasingly 
recognized.  One  of  the  chief  objects  of  the 
home  visit  is  to  observe  the  child's  sleeping  ar- 
rangements, and  this  need  is  sometimes  as  great 
in  the  homes  of  the  wealthy  as  among  the  poor. 
For  example,  two  growing  girls  in  a  family  of 
wealth  were  found  to  be  sleeping  in  a  room 

199 


NUTRITION  AND  GROWTH  IN  CHILDREN 

lined  with  heavy  draperies,  with  their  beds  close 
against  the  wall  in  corners  filled  with  dead  air. 
Their  father  was  so  afraid  of  drafts  that  he 
was  in  the  habit  of  getting  up  in  the  night  to 
close  all  windows  that  chanced  to  be  open. 

One  of  the  daughters  later  went  around  the 
world  to  search  for  the  health  that  could  have 
been  found  at  home  by  remedying  the  condi- 
tions just  described.  Her  sister  has  had  severe 
attacks  of  pleurisy,  and  is  probably  tuberculous, 
but,  although  she  is  now  a  trained  social 
worker,  she  is  not  able  to  get  away  from  the 
habits  and  prejudices  of  her  childhood,  and  still 
sleeps  with  her  windows  tightly  closed. 

An  occasional  visit  to  the  home  at  night  will 
often  lead  to  a  better  understanding  of  the 
child's  case.  Frequently,  children  will  be 
found  to  sleep  facing  the  light,  with  beds 
against  the  wall  in  a  dead  air  space  and  only 
one  window  open,  which,  moreover,  may  be 
away  from  the  prevailing  wind.  Even  that  sin- 
gle window  is  often  kept  closed  until  the  par- 
ents retire,  which  may  be  several  hours  after 
the  children  have  gone  to  bed.  Growing  chil- 
dren need  fresh  air  every  hour  of  the  twenty- 
four. 

In  dealing  with  those  in  less  favorable  cir- 
cumstances it  must  be  borne  in  mind  that  the 

200 


THE  NUTRITION  WORKER 

more  igiiorant  a  person  is,  the  easier  it  is  to 
hurt  his  feelings.  It  is  a  good  rule  to  meet  all 
parents  in  such  a  way  as  to  bring  out  their  best 
qualities,  and  to  see  as  much  good  and  as  little 
bad  in  the  situation  as  possible.  The  nutrition 
worker  must  ''know  people,"  and  realize  the 
significance  of  human  relationships.  She  must 
be  able  to  appraise  the  resources  that  are  avail- 
able, and  to  grasp  quickly  the  needs  of  a  sit- 
uation. 

Encouragement  should  be  given  for  what  the 
parents  are  trying  to  do.  Even  capable  persons 
become  like  children  when  over-strained  or  ill, 
and  require  advice  and  assistance  to  start  a 
constructive  program  of  action.  The  mother's 
point  of  view  is  based  on  experience  with  her 
own  children,  while  the  worker's  ideas  are  the 
result  of  clinical  training.  This  wider  vision 
should  be  used  to  give  clearer  definition  to  the 
part  the  mother  must  bear  in  carrying  out  the 
child's  program. 

Family  Types. — The  families  with  which  the 
nutrition  worker  has  to  deal  fall  into  two 
groups.  The  first,  and  fortunately  by  far  the 
larger,  seeks  to  cooperate  and  shows  apprecia- 
tion of  help  in  meeting  difficulties  that  have 
proved  too  complicated  to  be  solved  alone.  This 
group  is  made  up  of  what  we  may  call  ''good 

201 


NUTRITION  AND  GROWTH  IN  CHILDREN 

motbers,"  while  the  second  includes  all  those 
who  are,  in  one  way  or  another,  "difiBcult." 

There  is  the  stubborn,  obstinate,  and  preju- 
diced type  who  does  not  really  wish  to  learn. 
Others  look  for  some  one  else  to  do  the  hard 
work,  yet  expect  praise  at  every  turn.  Many 
are  overindulgent,  easygoing,  and  quite  lacking 
in  home  control.  Here  we  find  the  ''spoiled 
child"  and  the  spoiled  mother  as  well!  Others 
are  simply  lacking  in  common  sense,  and  are 
irresponsible  to  such  an  extent  that  one  can 
never  "put  his  finger  on  them."  Still  others 
are  overanxious  and  fearful.  There  are  always 
a  few  w^ho  are  shiftless,  vicious,  or  mentally 
deficient.  The  latter  class  includes  many  forais 
of  subnormality  which  are  menaces  to  the  com- 
munity, and  the  nutrition  worker  should  see  that 
they  are  turned  over  to  agencies  having  experts 
especially  trained  to  care  for  them. 

To  meet  such  problems  the  worker  must  have 
an  understanding  of  human  nature,  and  be  able 
to  grasp  the  strong  and  weak  points  in  every 
situation.  By  some  means  each  family  with 
which  she  has  to  deal  must  be  controlled  until 
there  is  a  beginning  of  order  and  responsibility. 
The  force  of  jDublic  opinion,  school,  church,  and 
every  other  helpful  factor  must  be  brought  to 
bear  when  needed. 

202 


THE  NUTRITION  WORKER 

In  caring  for  families  of  this  latter  kind  the 
worker  must  not  neglect  others  of  the  first 
group  with  whom  results  can  more  readily  be 
obtained.  In  one  clinic  several  workers  were 
exhausting  their  resources  on  a  family  in  which 
the  mother  was  found  to  be  so  mentally  defec- 
tive that  their  efforts  were  largely  wasted. 
Another  mother  had  been  on  the  roll  of  the  same 
clinic  for  six  years,  receiving  medicine  from 
time  to  time  but  so  little  definite  instruction  that 
her  children  did  not  improve.  This  mother  was 
intelligent  and  ready  to  cooperate  fully.  When 
she  brought  her  children  to  the  nutrition  class, 
and  received  definite  instruction  as  to  their 
food  and  health  habits,  they  went  "over  the 
top"  ^  in  a  few  weeks'  time. 

In  one  nutrition  class  we  were  told  it  was 
impossible  to  secure  the  attendance  of  the  moth- 
ers. On  investigation  it  was  found  that  the 
nurses  in  charge  were  issuing  orders  for  food 
and  other  supplies  for  these  homes,  and  there- 
fore could  have  had  the  whip  hand,  although 
they  were  letting  the  mothers  hold  the  club  over 
them.  As  a  result,  the  children  in  this  clinic 
were  averaging  only  112  per  cent  of  the  ex- 

^  This  expression  is  used  to  acknowledge  the  child's 
achievement  when  his  actual  weight  line  reaches  the  line 
representing  the  average  weight  for  his  height. 

203 


NUTRITION  AND  GROWTH  IN  CHILDREN 

pected  gain  in  weight,  while  a  few  blocks  away, 
where  the  cooperation  of  the  mothers  had  been 
insisted  upon,  children  from  the  same  type  of 
families  were  gaining  at  the  rate  of  369  per 
cent. 

Nutrition  work  has  for  its  foundation  the 
love  of  the  parent  for  the  child,  but  the  nutri- 
tion w^orker,  to  be  successful,  must  see  that  this 
natural  affection  is  directed  into  the  proper 
channel,  and  the  parents  held  responsible  for 
their  part  in  every  instance. 

Interest  in  Children. — All  that  the  worker  can 
do  in  the  way  of  organization,  administration, 
and  teaching,  however,  counts  for  little  unless 
she  understands  and  cares  for  the  children 
themselves.  She  must  have  a  zeal  for  getting 
children  well,  guided  by  intelligence  and  a 
sense  of  proportion.  These  latter  qualities  are 
particularly  important,  for  nothing  is  more  dis- 
couraging than  to  spend  one's  self  without  stint, 
only  to  find  that  lack  of  essential  knowledge 
has  rendered  all  this  labor  unavailing.  The  in- 
domitable spirit  which  is  bound  to  carry  a  child 
through  to  normal  standards  of  health  must  not 
be  allowed  to  waste  itself  through  inadequate 
methods. 

There  is  also  the  danger  that  the  worker  may 
become  so  attached  to  a  particular  child  that 

204 


THE  NUTRITION  WORKER 

she  unconsciously  seeks  to  keep  him  under  her 
care  rather  than  to  use  her  best  efforts  to  find 
out  what  it  is  that  the  child  really  needs.  Cer- 
tain borderline  mental  cases  show  an  excessive 
affection  which  appeals  to  the  worker  for  an 
undue  share  of  time  and  attention.  All  these 
complications  should  be  considered  in  the  light 
of  the  highest  good  of  the  individual  and  full 
justice  to  the  whole  group. 

The  Appeal  of  Nutrition  Work. — What  is  at- 
tracting high  grade  workers  from  other  fields 
to  this  new  form  of  service?  The  first  answer 
is  that  there  is  real  satisfaction  in  doing  w^ork 
that  has  results  that  can  be  definitely  measured. 
The  weight  chart  gives  evidence  that  cannot  be 
denied.  When  the  weekly  weighing  has  been 
finished,  the  nutrition  worker  knows  how  many 
of  the  children  are  on  the  right  track,  and  also, 
what  is  equally  important,  how  many  unsolved 
problems  remain  to  challenge  her  best  powers. 

Another  aspect  of  the  work  is  seen  in  the 
comment  of  a  young  college  woman,  ''The  work 
is  so  human!"  The  nutrition  worker  enjoys 
her  association  with  mothers  and  children  in 
the  class  group,  and  is  as  happy  as  they  over 
the  gains  made.  There  is  no  greater  satisfac- 
tion than  that  of  seeing  a  sick  child  return  to 
health.     A  malnourished  child  who  has  been 

205 


NUTRITION  AND  GROWTH  IN  CHILDREN 

retarded  physically  and  mentally,  a  trial  to  him- 
self and  his  teachers,  shows  an  actual  trans- 
formation when  he  is  brought  to  normal  devel- 
opment. The  improvement  in  his  condition  is 
reflected  in  the  atmosphere  of  both  home  and 
school,  and  the  nutrition  worker  may  justly  feel 
that  her  efforts  have  contributed  to  the  welfare 
of  the  community. 

The  opportunity  that  comes  to  the  nutrition 
worker  is  as  truly  significant  in  saving  life  as 
that  afforded  by  some  dramatic  surgical  opera- 
tion. In  setting  children  upon  the  road  to 
health  she  is  saving  them  from  permanent 
physical  unfitness  and  rendering  a  high  form  of 
public  service. 


CHAPTER  XIX 

THE  PHYSICIAN   AND   THE  NUTRITION   CLASS 

A  NUTEiTiON  class  is  not  conducted  for  diver- 
sion or  amusement,  for  academic  discussion,  or 
for  the  purpose  of  philosophizing  about  the  gen- 
eral value  of  health.  It  is  a  strictly  business 
gathering,  and  the  business  to  be  accomplished 
is  to  get  the  children  well.  If  this  purpose  is 
to  be  realized  with  anything  more  than  ordinary 
efficiency,  the  physician  should  be  present  at 
every  meeting.  He  need  not  spend  more  than 
half  an  hour  with  the  class,  for  in  that  time  he 
can  bring  out  as  many  points  as  can  be  remem- 
bered. 

By  the  time  the  physician  comes  in,  the  nutri- 
tion worker  has  weighed  the  children,  checked 
up  the  diet  lists  and  the  week's  activities,  given 
the  stars  for  lunches  and  rest  periods,  and  ar- 
ranged the  children  and  their  mothers  in  the 
order  of  the  gains  made.  The  charts  are  hung 
in  a  line  in  the  same  order,  to  show  the  physi- 
cian the  progress  made  since  his  last  visit.  The 
class  meeting  is  a  vital  feature  of  nutrition 
work,  and  presents  a  psychological  opportunity 

207 


NUTRITION  AND  GROWTH  IN  CHILDREN 

in  which  much  can  be  accomplished  with  a  mini- 
mum of  effort. 

The  nutrition  worker  has  had  conferences 
with  the  parents  and  the  children.  She  knows 
their  problems,  their  efforts  to  overcome  dif- 
ficulties, and,  in  many  cases,  the  causes  of  fail- 
ure. The  physician  comes  in  as  the  final  au- 
thority to  observe  the  results  of  recommenda- 
tions previously  made  and  to  give  further  ad- 
vice as  needed. 

He  first  notes  the  gains  made,  taking  pains  to 
give  each  child  who  has  gained  proper  credit 
for  his  effort.  The  child  is  entitled  to  such 
praise  as  "That's  a  good  record,"  "You  have 
done  well,"  etc.  These  words  should  be  spoken 
clearly  so  that  all  may  hear  and  the  child  may 
feel  that  his  efforts  have  been  recognized.  The 
children  are  thus  encouraged  to  continue,  and 
suggestions  are  made  to  help  them  increase 
their  gain.  Too  much  time  must  not  be  spent 
with  this  group,  however,  and  the  physician 
must  pass  on  to  those  children  who  have  not 
gained,  usually  about  one-fourth  of  the  total 
number.  These  present  the  physician's  special 
problem. 

Where  a  child  has  not  gained  there  is  always 
a  cause.  This  cause  is  either  social,  in  which 
case  the  responsibility  rests  with  the  nutrition 

208 


THE  PHYSICIAN  AND  THE  CLASS 

worker,  or  it  is  medical,  when  it  is  the  physi- 
cian's business  to  find  it,  and  he  has  not  ful- 
filled his  duty  until  he  has  done  so.  In  these 
cases  he  must  carry  his  analysis  further,  ques- 
tioning both  child  and  parent  to  see  if  directions 
previously  given  have  been  carried  out,  and 
going  over  again  the  five  chief  causes  of  mal- 
nutrition. 

Beginning  with  physical  defects,  he  will  re- 
ceive from  the  nutrition  worker  the  report  on 
the  defects  that  have  been  corrected  and  those 
that  remain  to  be  done ;  how  many  children  are 
waiting  for  adenoid  and  tonsil  operations,  etc., 
and  the  reason  for  the  delay  in  each  case.  This 
may  be  fear  on  the  part  of  the  parents  or  merely 
postponement  until  a  more  convenient  time. 
He  must  convince  the  parents  by  the  record  of 
the  charts  and  by  all  other  available  means  of 
the  necessity  of  having  the  defects  corrected. 
Almost  invariably  the  child  who  has  not  gained 
is  found  to  be  the  child  who  has  not  followed  di- 
rections. 

This  leads  at  once  to  the  question  of  Jiome 
control,  and  perhaps  the  most  essential  part  of 
the  class  work  is  with  the  mothers.  If,  for  ex- 
ample, the  child  has  not  taken  his  rest  periods 
we  ask  the  mother  why,  and  tell  her  she  is  re- 
sponsible for  this  part  of  the  program,  and  in 

209 


NUTRITION  AND  GROWTH  IN  CHILDREN 

fact  for  all  directions  given  that  are  to  be  car- 
ried out  in  the  home.  These  will  cover  most  of 
the  points  relating  to  overfatigue  and  the 
child's  food  and  health  habits.  The  mother 
must  be  convinced  of  her  responsibility  in  get- 
ting her  child  well,  and  should  not  be  lightly 
excused  for  failure  to  follow  directions.  She 
must  be  shown  that  by  obeying  instructions  she 
is  not  only  preventing  sickness,  but  possibly 
saving  her  child's  life. 

Where  directions  have  not  been  followed,  it 
is  remarkable  what  effect  the  public  opinion  of 
the  group  has  on  the  delinquent  mother.  She 
rarely  has  the  moral  courage  to  continue  coming 
to  the  class  without  making  the  changes  recom- 
mended in  her  child's  program,  knowing  that 
this  will  be  brought  to  light  in  case  there  is 
failure  to  gain. 

A  convincing  demonstration  is  given  when  a 
child  who  has  gained  is  asked  to  stand  up  before 
the  group  with  a  child  who  has  not  gained.  The 
mothers  learn  to  notice  improvement  from  week 
to  week  with  almost  the  same  keenness  as  the 
doctor  and  when  one  mother  sees  the  results 
secured  by  another  whose  child  has  carefully 
followed  instructions,  the  result  is  apt  to  be 
very  different  in  the  case  of  her  own  child  the 
following  week. 

210 


Figure  32.     the  child  as  an  object  lesson 

These  two  girls,  JJarsaret  and  Irene,  afford  a  comparison  of  results. 
Margaret  had  stopped  drinking  lea.  had  taUen  lier  lunches  and  rest 
periods  laithfiilly  and  followid  all  directions,  with  a  consc(pient  gain  of 
1  i/L'  pounds,  which  placed  hei  at  the  hrnd  of  the  class  for  the  week. 
Irene,  who  stands  at  the  right,  was  at  the  foot  of  the  class  heeause 
sue  liad  failed  to  gain.  Her  molher  was  afraid  shi-  would  take  cold  if 
her  windows  were  open  at  niglit.  She  was  allowed  to  select  her  own 
food  and  to  indulge  in  "hanana  si)lits"  hetween  meals.  Seeing  the 
gains  made  h.v  the  other  children,  her  mother  agreed  to  have  tl)e 
windows  opened,  and  Iiriir  ciuMe(t<'d  her  had  food  habits. 
The  following  week  she  made  a  good  gain. 


THE  PHYSICIAN  AND  THE  CLASS 

The  physician  should  not  take  this  occasion 
to  lecture  or  to  give  general  advice.  Each  point 
brought  out  should  be  demonstrated  by  the 
weight  chart  and  by  the  child  himself.  In  this 
way  teaching  is  done  by  example  and  by  visual- 
ization, which  is  perhaps  the  most  effective 
method  of  education. 

There  is  a  fine  spirit  of  truthfulness  and 
honor  in  the  nutrition  class  and  the  relation  be- 
tween the  children  and  the  physician  becomes 
one  of  mutual  trust  and  cooperation.  The  de- 
sire to  gain  is  so  keen  that  their  attitude  is, 
"What  can  I  do?"  and  "How  can  you  help 
me?" 

Points  are  brought  out  in  these  class  meetings 
that  would  never  be  discovered  otherwise.  For 
example,  a  boy  who  had  not  gained  asked  if 
reading  in  bed  before  breakfast  would  interfere 
with  his  gaining ;  a  little  girl  said  she  slept  with 
windows  closed  for  fear  a  cat  would  get  into  her 
room  at  night ;  another  child  had  been  kept  after 
school  to  help  correct  examination  papers ;  and 
we  frequently  find  a  child  attending  daily  re- 
hearsals for  entertainments  when  he  is  already 
suffering  from  overfatigue. 

The  children  are  always  interested  in  one 
another,  and  the  mothers  become  interested  in 
every  child  in  the  class ;  thus  all  learn  from  the 

211 


NUTRITION  AND  GROWTH  IN  CHILDREN 

general    experience,    provided    the    physician 
brings  out  each  point  clearly. 

"With  the  indifferent  mother  the  physician 
must  be  skillful  in  appealing  to  the  influence  to 
which  she  is  most  susceptible.  In  one  case  it 
may  be  her  love  for  the  child  and  her  desire  to 
have  him  well ;  in  another,  public  opinion  may  be 
the  most  potent  lever;  another  mother  may  be 
reached  through  a  sense  of  shame  in  seeing  her 
child  at  the  foot  of  the  class;  others  are  flat- 
tered by  receiving  the  attention  of  the  physician 
and  the  nutrition  worker,  but  all  have  a  feeling 
of  pride  and  satisfaction  in  seeing  any  child 
in  the  class  return  to  health. 

The  questions  asked  should  be  definite 
and  definite  answers  should  be  required. 
*'Why  have  you  not  taken  your  rest  periods?" 
Certain  mothers  need  to  be  addressed  in  a  thor- 
oughly businesslike  manner.  *'Do  you  want  to 
play  this  game  or  not?"  *'If  you  don't  in- 
tend to  obey  instructions,  do  not  bring  your 
child  in  again."  "Does  health  mean  more  to 
you  than  education,  or  do  you  value  education 
more  than  health?"  "If  you  think  your  child's 
health  the  more  important,  then  do  not  talk  to 
me  any  more  about  promotions  or  what  he  is 
missing  in  school.  He  has  all  his  life  to  study 
but  only  a  few  years  to  grow. ' ' 

212 


THE  PHYSICIAN  AND  THE  CLASS 

The  nutrition  class  aids  the  mother  in  estab- 
lishing control  over  her  child.  When  the  boy 
or  girl  wants  to  get  well,  and  the  program 
recommended  to  accomplish  this  calls  for  plenty 
of  sleep,  regular  meals,  and  the  correction  of 
faulty  food  and  health  habits,  the  occasion  for 
parental  discipline  in  these  matters  is  removed 
and  the  problem  of  home  control  is  greatly 
simplified.  Therefore,  when  directions  are 
clearly  given  to  the  mother  in  the  presence  of 
the  child,  and  we  exj^lain  to  both  the  absolute 
necessity  of  their  being  followed,  they  return 
home  with  an  equal  desire  to  carry  out  the  pro- 
gram and  get  results.  The  child  will  now  work 
with  the  mother  in  the  same  way  in  which  a 
good  soldier  2:)romptly  obeys  an  officer  who  has 
learned  to  give  the  proper  orders.  In  each  case 
the  problem  of  discipline  is  largely  eliminated. 

So  helpful  has  the  class  been  in  improving 
home  control  that  we  have  been  asked  re- 
peatedly by  mothers  to  continue  the  classes  dur- 
ing the  summer  for  this  reason  alone. 

On  several  occasions  I  have  hesitated  about 
holding  a  class  meeting  in  especially  bad 
weather,  but  on  telephoning  to  inquire  about 
the  attendance  have  found  it  to  be  practically 
normal.  When  once  aroused  to  the  importance 
of  the  class,  neither  mother  nor  child  will  allow 

213 


NUTRITION  AND  GROWTH  IN  CHILDREN 

anything  to  interfere  with  their  attendance. 
One  mother  brought  her  boy  of  seven  to  the 
class  by  carrying  one  child  in  her  arms  and  ar- 
ranging with  a  neighbor  for  the  care  of  another. 
To  reach  the  class  on  time  she  was  obliged  to 
rise  at  five  in  the  morning  but  rarely  missed 
a  meeting  during  two  whole  winters,  although 
on  some  days  the  thermometer  was  below  zero. 
The  power  for  health  that  may  be  generated 
in  such  a  class  through  the  combined  efforts  of 
physician,  nutrition  worker,  parent,  and  child 
is  remarkable. 


CHAPTER  XX 

REPORT  OF   A   CLASS  MEETING 

To  illustrate  what  can  be  taught  in  less  than  a 
half  hour's  time  by  means  of  the  nutrition  class, 
the  following  report  of  a  recent  meeting  is 
given.  This  class  is  connected  with  a  nutrition 
clinic  at  a  large  hospital,  and  is  selected,  not  be- 
cause of  exceptional  results,  but  because  it  pre- 
sents rather  more  than  the  usual  number  of 
problems,  and  the  group  is  largely  from  a  neigh- 
borhood in  which  strong  cooperation  of  the 
schools  is  lacking. 

The  attendance  on  the  day  of  this  meeting 
was  fourteen  children  and  nine  mothers.  The 
class  had  been  organized  only  a  few  weeks,  and 
was  being  gradually  increased.  Four  new  chil- 
dren came  in  with  their  mothers  for  the  first 
examination,  and  two  others  had  been  sent  for 
examination  from  other  departments  of  the  hos- 
pital, only  eight  having  previously  been  regu- 
larly admitted  to  the  class  and  given  charts. 
These  eight  were  seated  according  to  their 
gains  in  the  following  order : 

1.  Florence  Z.  (age  eleven,  17  per  cent  un- 
215 


NUTRITION  AND  GROWTH  IN  CHILDREN 

derweiglit)  occupied  the  seat  of  honor  at  the 
head  of  the  class,  having  gained  one  and  one- 
half  pounds.  She  had  taken  her  lunches  and 
rest  periods  without  missing  a  single  day,  and 
was  pleased  to  stand  up  that  the  other  children 
and  the  mothers  might  see  her  improvement, 
which  was  evident  in  her  general  appearance 
and  better  color.  Her  mother  said,  "I  chase 
her  to  bed  since  coming  here." 

2.  Morton  B.  (age  fourteen,  10  per  cent  un- 
derweight) gained  one  and  one-quarter  pounds. 
This  boy's  stepmother  had  been  unwilling  to 
have  him  excused  from  school  for  his  mid-morn- 
ing lunch  and  rest  period,  but  as  this  meeting 
was  during  vacation  he  had  taken  both  faith- 
fully. As  his  previous  average  gain  had  been 
only  two  ounces,  this  week's  record  of  twenty 
ounces  was  conclusive  evidence  to  the  mother  of 
the  significance  of  overfatigue  from  school 
work.  She  therefore  asked  for  a  note  to  have 
Morton  excused  from  school  at  10:30  that  he 
might  continue  his  mid-morning  lunch  and  rest 
period. 

3.  Stephen  B.  (age  thirteen,  17  per  cent  un- 
derweight), who  gained  one  and  one-quarter 
pounds,  was  a  newsboy  and  particularly  active. 
He  had  previously  thought  it  not  worth  while 
to  go  to  bed  early  because  he  could  not  fall 

216 


A  CLASS  MEETING 


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FiGTTRE    33.      SCHOOL   HOURS   REDUCED 

Muriel  M.  had  lipen  foHowIn?  all  diroctions  for  pl^ht  weeks  without 

niakin::  progress  towards  her  normal  weight  line.     FoUowidc  a  visit 

to   the  class,   her  toacher  excused   her  at   10:30   for  a   mid  morning 

rest  period.     The  subsequent  gain  confirmed  the  diagnosis 

of  overfatigue  from  too  long  school  hours. 

asleep  at  once,  and  had  therefore  been  staying 
up  as  late  as  11  or  12  o'clock  at  night.  When 
it  was  explained  to  him  that  he  could  rest  even 

217 


NUTRITION  AND  GROWTH  IN  CHILDREN 

when  not  sleeping,  he  agreed  to  take  more  rest 
and  the  week's  good  gain  proved  that  this  was 
clearly  a  case  of  overfatigue  from  late  hours. 

4.  Rose  E.  (age  nine,  5  per  cent  under- 
weight) gained  only  one-quarter  of  a  pound, 
which  had  been  her  average  gain  for  four  weeks. 
She  had  been  advised  to  have  an  adenoid  and 
tonsil  operation,  and  her  small  gain,  although 
all  directions  had  been  faithfully  followed,  con- 
firmed earlier  evidence  of  the  harmful  effect  of 
her  diseased  tonsils.  An  appointment  was  ac- 
cordingly made  at  once  for  the  operation. 

5.  Muriel  M.  (age  twelve,  5  per  cent  under- 
weight) had  not  gained,  although  she  had  tried 
to  follow  instructions.  Her  mother  had  been 
ill  with  pneumonia,  and  Muriel  had  been  doing 
extra  work  at  home.  Her  teacher  visited  the 
class  this  morning,  and  seeing  Muriel's  chart 
and  having  her  condition  demonstrated,  prom- 
ised to  adjust  the  child's  school  program  so 
that  she  might  be  excused  at  10 :30  for  a  lunch 
and  rest  period  until  she  reached  normal 
weight.     (See  Figure  33.) 

6.  John  D.  (age  seven,  10  per  cent  under- 
weight) also  failed  to  gain,  and  the  nutrition 
worker  found  the  cause  here  was  lack  of 
home  control.  The  mother  remarked  with  little 
apparent  concern  that  John  did  not  mind  her 

218 


A  CLASS  MEETING 

when  she  called  him  in  from  play.     She  was 
then  asked  the  following  questions : 

**Who  runs  your  home,  you  or  your  husband?" 
Answer.  "My  husband  gives  me  the  money,  and  I 
run  the  house. ' ' 

"How  much  does  your  boy  weigh  1"  Answer. 
"Forty  pounds." 

"How  much  do  you  weigh?"  Answer.  "One  hun- 
dred and  forty  pounds." 

"Do  you  mean  to  say  that  you,  who  weigh  140 
pounds,  cannot  control  your  boy  of  seven  who  weighs 
only  40  pounds?"  Answer.  "Of  course  I  can  make 
him  mmd." 

"Then,  Mrs.  D.,  why  don't  you  make  him  come  in 
for  his  rest  periods?"    No  answer. 

The  physician  continued : 

"There  is  no  use  in  your  boy  coming  here  week 
after  week  unless  there  is  some  one  in  authority  over 
him  with  whom  I  can  do  business.  If  you  can  run 
your  house,  you  should  be  able  to  make  your  boy 
mind.  I  suggest  if  John  goes  out  to  play  and  fails 
to  come  in  at  the  proper  time,  that  you  go  after  him 
and  keep  him  in  until  he  promises  to  obey  you.  We 
depend  on  you  to  follow  directions. ' ' 

The  mother  promised  '*to  attend  to  him"  the 
following  week. 

7,    Alfred  H.  (age  eleven,  17  per  cent  under- 
219 


NUTRITION  AND  GROWTH  IN  CHILDREN 

weight)  weighed  just  the  same  as  at  the  last 
meeting.  He  had  been  a  very  difficult  problem 
case  for  more  than  three  years,  with  no  relative 
gain  in  weight.  His  continued  failure  to  gain 
indicated  that  there  was  some  serious  underly- 
ing cause.  Five  consultations  had  been  held, 
and  much  laboratory  work  performed  without 
success  in  determining  the  real  cause  of  his 
poor  condition.  The  preceding  week  a  radio- 
graph of  the  digestive  tract  had  been  made,  and 
Alfred  had  come  in  to  hear  a  report  of  the  ex- 
amination. The  results  showed  signs  of  possi- 
ble intestinal  adhesions,  and  arrangements  were 
accordingly  made  to  send  the  boy  to  the  hospital 
for  treatment.^     (See  Figure  7.) 

8.  Thomas  M.  (age  twelve,  15  per  cent  un- 
derweight) had  lost  one-half  pound.  He  was  11 
pounds  under  the  average  weight,  but  his 
mother  thought  if  he  were  in  bed  12  hours  at 
night,  he  did  not  need  extra  rest  during  the  day. 
She  was  reminded  that  the  average  well  man 

^  Further  tests  and  examinations  in  the  ward  confirmed 
thp  Roentgen-ray  finding's,  which  evidence,  supported  by 
tlie  long  failure  i>  gain  under  otherwise  favorable  condi- 
tions, led  to  the  decision  to  make  an  exploratory  abdominal 
operation.  This  operation  showed  bands  across  the  du- 
odenum (probably  congenital)  that  adequately  3xplained 
his  poor  nutrition.  He  is  now  gaining  steadily,  and  on  the 
road  to  complete  recovery. 

220 


A  CLASS  MEETING 

found  8  or  9  hours'  work  a  day  suflScient, 
and  told  that  she  should  not  allow  her  under- 
nourished boy  to  expend  his  energy  for  12  con- 
secutive hours  practically  without  rest.  She 
promised  to  have  him  take  a  half  hour's  rest 
before  both  dinner  and  supper,  and  mid- 
morning  and  mid-afternoon  lunches  at  a  regular 
time. 

Thus  by  bringing  into  play  the  four  forces 
that  safeguard  the  child's  health,  namely,  the 
home,  medical  care,  the  school,  and  the  child's 
own  interest,  a  single  meeting  of  the  nutrition 
class  produced  results  in  a  space  of  less  than 
30  minutes  that  it  would  have  required  hours  of 
individual  work  to  accomplish. 


CHAPTER  XXI 

THE  NUTRITION   OB  DIAGNOSTIC  CLINIC 

In  nutrition  work  we  are  constantly  meeting 
children  who  have  been  the  subject  of  extensive 
medical  study  without  showing  marked  im- 
provement. They  may  have  been  under  the 
care  of  various  child-helping  organizations,  and 
have  passed  through  several  hospital  depart- 
ments. Even  after  the  thorough  physical- 
growth,  mental,  and  social  examinations  of  the 
nutrition  class,  there  will  always  remain  a  cer- 
tain number  of  children  who  do  not  respond  to 
treatment,  and  whose  charts  after  weeks  and 
even  months  show  practically  no  gain  in 
weight.  Such  cases  are  a  drag  on  the  class,  and 
if  they  are  in  too  large  a  proportion  to  the  total 
number,  there  results  discouragement  and  lack 
of  interest  on  the  part  of  the  whole  group. 

The  nutrition  class  is  not  only  a  helpful  means 
of  treatment,  but  also  an  aid  in  securing  correct 
diagnosis  of  these  difficult  cases.  The  failure  of 
growing  children  to  gain  when  all  the  known 
causes  that  would  interfere  with  their  progress 
have  been  eliminated  is  a  significant  indication 

222 


THE  NUTRITION  CLINIC 

that  there  is  some  physical  cause  that  has  been 
previously  overlooked.  The  child  who  does  not 
gain  under  such  conditions  is  most  probably 
not  ''free  to  gain,"  and  after  a  trial  of  four  or 
five  weeks  in  the  nutrition  class,  should  be  sent 
to  a  nutrition,  or  diagnostic,  clinic. 

Such  a  clinic  is  most  effective  when  connected 
with  a  hospital,  where  all  the  resources  of  that 
institution  may  be  called  into  service  if  neces- 
sary. The  clinic  should  work  in  close  coopera- 
tion with  the  various  specialists  on  the  hospital 
staff,  and  secure  special  tests  and  expert  advice 
according  to  the  needs  of  the  individual  child. 
Observation  over  a  number  of  months  is  some- 
times necessary  and  Roentgen-ray,  Wasser- 
mann,  von  Pirquet,  skin  proteid  tests,  and  much 
laboratory  work  may  be  required  before  the 
correct  diagnosis  can  be  made.  Among  the  ob- 
scure causes  of  malnutrition  thus  found  in  the 
diagnostic  clinic  may  be  mentioned  cardio- 
spasm, anaphylaxis,  chronic  appendicitis,  in- 
testinal parasites,  pyelitis,  hereditary  syphilis, 
tuberculosis,  and  sinus  infection. 

The  nutrition  clinic  should  be  an  important 
department  of  the  children's  out-patient  depart- 
ment of  every  hospital,  with  a  nutrition  class  as 
part  of  its  organization,  for  the  purpose  of  ob- 
serving the  child  under  controlled  conditions. 

223 


NUTRITION  AND.  GROWTH  IN  CHILDREN 

In  order  that  it  may  operate  effectively,  it  must 
be  a  rule  of  the  hospital  that  all  children  who 
apply  for  treatment  shall  be  weighed  and  meas- 
ured, and  those  found  to  be  underweight  sent 
to  the  nutrition  clinic  automatically.  The  nu- 
trition clinic  serves  a  fourfold  purpose: 

1.  It  relieves  the  special  departments  by  tak- 
ing care  of  simple  cases  of  malnutrition  in  its 
nutrition  class. 

2.  It  gives  opportunity  to  study  problem 
cases  sent  in  from  nutrition  classes  in  neighbor- 
ing schools  and  community  centers,  and  directs 
the  progress  of  unsolved  cases  from  one  depart- 
ment of  the  hospital  to  the  other.  The  com- 
pleteness of  its  history  and  examination  form 
assists  the  special  departments  by  supplying 
data  that  aid  in  their  diagnosis  and  treatment. 

3.  It  offers  a  demonstration  in  first-hand 
health  instruction  to  parents,  teachers,  students, 
social  workers,  nurses,  and  physicians. 

4.  It  acts  as  a  clearing  house  for  children 
who  most  need  the  benefit  of  summer  camps, 
outings,  or  institutional  care. 

The  attendance  of  the  parents  is  necessary 
at  every  meeting  of  the  nutrition  clinic.  "When 
both  parents  are  present  the  diagnosis  is  fre- 
quently made  clear  at  once.  Their  observation 
of  the  child  in  bis  normal  environment  at  home 

224 


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THE  NUTRITION  CLINIC 

may  be  more  illuminating  than  that  of  specially 
trained  observers  in  the  unaccustomed  sur- 
roundings of  ward  or  institution. 

When  the  attendance  of  the  father  is  re- 
quested, the  usual  answer  is  that  he  cannot 
leave  his  work.  Before  such  a  reply  is  ac- 
cepted, the  matter  should  be  taken  up  with 
his  employer,  who  should  welcome  this  as  an 
opportunity  to  establish  more  human  relations 
with  his  employee  by  making  such  adjustments 
as  may  be  necessary  to  allow  him  to  be  absent 
an  hour  a  week  to  help  his  child  to  get  well. 
When  the  importance  of  such  cooperation  is 
fully  explained,  the  case  is  rare  where  it  cannot 
be  secured. 

A  useful  adjunct  to  such  a  diagnostic  clinic  is 
a  nutrition  camp  or  station  under  its  control, 
where  children  may  be  sent  to  note  their  reac- 
tion to  changed  environment  when  it  is  sus- 
pected that  the  causes  of  their  malnutrition 
are  social  rather  than  medical.  Such  a  camp  is 
more  useful  for  diagnostic  purposes  than  a  bed 
in  a  hospital,  provided  the  child  is  under  the 
observation  of  a  trained  nutrition  worker  who 
can  note  the  child's  reaction  to  his  surround- 
ings, to  other  children,  and  to  the  authority  of 
the  camp.  All  this  is  valuable  evidence  for 
mental  and  social  as  well  as  for  physical  diag- 

225 


NUTRITION  AND  GROWTH  IN  CHILDREN 

nosis.  Cases  whose  diagnosis  iias  remained  ob- 
scure for  weeks  and  months  in  the  nutrition 
class  and  the  hospital  often  become  clear  in  a 
few  days  under  such  controlled  observation.^ 

When  admitted  to  the  camp,  the  children 
should  be  accompanied  by  their  parents,  who 
should  also  make  regular  visits  at  the  time  of 
the  weekly  weighing,  in  order  that  they  may 
understand  thoroughly  just  what  is  being  done 
for  their  child,  and  so  continue  the  treatment 
when  he  returns  home. 

Children  frequently  gain  four  or  five  pounds 
in  a  single  week  at  such  a  camp,  even  though 
they  are  given  no  more,  and  no  better,  food 
than  they  were  taking  at  home.  This  is  a  con- 
vincing demonstration  to  the  parents  that  the 
regular  routine  with  its  rest  periods,  mid-morn- 
ing and  afternoon  lunches,  and  freedom  from 
disturbing  influences,  is  the  cause  of  the  child's 
improvement,  and  that  the  same  program  car- 
ried out  at  home  will  continue  the  good  accom- 
plished. 

It  must  be  borne  in  mind  that  the  responsi- 
bility for  the  child's  health  always  rests  with 
the  parent,  and  therefore  all  efforts  should  be 


^  In  Figure  44  we  show  the  results  accomplished  in  such 
a  camp  at  Grand  Rapids,  Michigan. 

228 


THE  NUTRITION  CLINIC 

directed  towards  helping  the  parents  in  their 
work,  not  even  temporarily  taking  such  respon- 
sibility from  their  hands.  Too  often  a  child  is 
given  special  privileges  in  an  open-air  school 
or  camp  with  a  consequent  improvement  in  his 
condition,  only  to  return  to  improper  diet  and 
faulty  health  habits  that  in  a  short  time  reduce 
him  to  his  former  poor  condition.  The  health 
education  that  comes  to  the  parent  through  ob- 
servation of  the  steps  taken  in  arriving  at  a 
correct  diagnosis  is  a  great  factor  in  making 
the  child's  recovery  permanent. 


CHAPTER  XXII 

MALNUTRITION   AND   THE  SCHOOL 

Educators  have  long  sought  a  means  of  bring- 
ing home  and  school  into  closer  association.  The 
nutrition  class  accomplishes  just  this  result. 
Attendance  of  the  parents  at  the  weekly  class 
meetings  brings  them  into  friendly  relations 
with  one  another  and  with  school  and  health 
authorities.  In  the  purpose  of  making  the  chil- 
dren well  they  are  united  in  an  atmosphere  of 
mutual  helpfulness,  which  promotes  a  better 
understanding  of  the  spirit  and  administration 
of  the  school. 

Parents  are  appreciative  of  what  the  school 
brings  to  the  child  in  the  way  of  culture  and 
opportunity,  but  when  it  is  also  the  agency 
through  which  the  undernourished  child  be- 
comes well  and  strong,  this  feeling  is  intensi- 
fied into  gratitude,  and  such  a  school  commands 
the  highest  loyalty  of  its  graduates  and  their 
parents. 

Effect  of  Malnutrition, — Children  who  are 
malnourished  react  abnormally,  and  suffer 
greatly    from    pressure    and    nagging.      This 

228 


MALNUTRITION  AND  THE  SCHOOL 

makes  them  either  callous  and  indifferent  to 
influences  that  are  needed  in  their  develop- 
ment, or,  in  the  effort  to  keep  pace  with  their 
class,  leads  to  disheartening  and  destructive 
overfatigue.  The  effect  of  this  condition,  more- 
over, is  not  confined  to  the  malnourished  pupils 
themselves.  Such  children  become  a  drag  on 
the  class,  and  despite  all  efforts  of  the  school 
authorities,  there  is  a  constant  tendency  to 
lower  standards.  While  those  who  are  unfit 
for  the  struggle  are  still  under  strain,  the  chil- 
dren who  are  well  able  to  do  full  work  suffer 
from  not  being  kept  up  to  their  normal  capac- 
ity. 

It  is  a  well  recognized  fact  among  physicians 
that  school  teachers  as  a  class  break  down  more 
frequently  than  do  members  of  any  other 
profession.  Many  teachers  are  only  malnour- 
ished children  grown  up,  without  ever  having 
had  knowledge  of  what  the  full  tide  of  health 
means.  They  have  no  surplus  energy,  and 
would  profit  by  the  nutrition  program  that  is 
provided  for  their  pupils.  Their  nervous  ten- 
sion is  constantly  reflected  in  the  health  of 
their  charges,  while  the  malnourished  children 
in  turn  react  on  the  overstrained  nerves  of 
their  teachers.  The  reduction  of  malnutrition 
will  therefore  lessen  the  burden  of  both  teach- 

229 


NUTRITION  AND  GROWTH  IN  CHILDREN 

ers  and  pupils,  and  greatly  increase  the  effi- 
ciency of  the  school. 

Extent  of  Malnutrition. — One-half  of  the  chil- 
dren in  public  and  private  schools  are  seriously 
underweight,  and  at  least  one-third  are  mal- 
nourished. Very  seldom  does  a  school  show 
less  than  this  proportion,  and  in  some  cases  the 
malnutrition  amounts  to  60  per  cent.  An  ex- 
amination of  the  entire  enrollment  of  one  of  our 
leading  private  schools,  one  that  has  influenced 
schools  abroad  as  well  as  in  this  country,  dis- 
closed the  fact  that  over  one-third  of  the  pu- 
pils were  more  than  seven  per  cent  underweight 
for  their  height,  and  had  other  unmistakable 
signs  of  malnutrition.  This  means  that  even  in 
the  homes  of  unusually  intelligent  and  thought- 
ful people  retarded  growth  has  been  unappreci- 
ated and  uncared  for. 

The  Nutrition  Program  in  the  School. — To 
combat  this  widespread  condition  the  nutrition 
program  should  begin  with  the  first  day  of  the 
child's  attendance.  No  child  should  be  admitted 
without  a  complete  physical  examination  in  the 
presence  of  both  his  parents.  The  situation  is 
serious  enough  to  warrant  the  few  minutes  of 
concentrated  attention  necessary  at  this  time 
in  order  to  save  the  loss  to  the  community  of 
large  numbers  of  backward  pupils  in  all  the 

230 


MALNUTRITION  AND  THE  SCHOOL 

grades,  and  from  30  to  40  per  cent  of  physically 
unfit  children  among  the  graduates. 


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FlGtTRE   35.      SCHOOL  EXAMINATIONS 

During  the  week  of  examinations  school  children  almost  invariably 
lose  from   %   to  2  pounds  in  weight. 

Every  pupil  should  be  weighed  and  measured 
once  a  year  and  re-weighed  once  a  month.  As 
there  will  always  be  a  certain  number  of  chil- 

231 


NUTRITION  AND  GROWTH  IN  CHILDREN 

dren  absent  at  the  time  of  the  weighing,  a  sys- 
tem should  be  inaugurated  by  which  these  chil- 
dren will  be  weighed  immediately  upon  their 
return.  If  cards  for  all  the  pupils  in  each  room 
are  made  out  in  advance,  the  person  in  charge 
of  the  weighing  will  be  able  to  keep  track  of  the 
absentees  and  check  up  their  records  when  they 
appear.  There  should  be  a  set  time,  prefera- 
bly at  the  opening  of  school  in  the  morning, 
when  these  children  are  sent  to  the  room  where 
the  weighing  and  measuring  is  done. 

This  follow-up  work  with  absent  children  is 
the  more  important  because  this  group  is  cer- 
tain to  contain  a  large  percentage  of  children 
whose  absence  is  caused  by  malnutrition  or  by 
acute  illness  which  is  apt  to  lead  to  this  condi- 
tion. The  gain  or  loss  revealed  by  the  weighing 
on  the  child's  return  to  school  should  be  the  test 
by  which  it  is  determined  whether  or  not  he  is 
ready  to  resume  full  work.  No  child  who  has 
been  absent  on  account  of  illness  for  more  than 
a  single  day  should  be  allowed  to  undertake  a 
full  program  until  he  has  regained  his  lost 
weight. 

Nutrition  classes  should  be  formed  of  the 
worst  cases,  beginning  with  the  children  who 
are  10  per  cent  or  more  underweight.  As  the 
first  members  graduate,  their  places  may  be 

232 


MALNUTRITION  AND  THE  SCHOOL 

filled  by  children  less  than  10  per  cent  under- 
weight, and  in  this  way  the  program  can  be 
extended  to  include  even  the  borderline  cases — 
those  less  than  seven  per  cent  below  the  average 
weight  for  their  height. 

The  School  Physician. — The  physician  for 
this  work  should  be  trained  and  experienced 
in  growth  standards.  At  present,  with  one  ex- 
ception, the  subject  of  malnutrition  is  not 
taught  in  our  medical  schools.  For  this  reason 
the  school  physician  requires  ;special  instruction 
and  supervision  in  nutrition  work. 

The  physician  must  have  the  final  authority 
to  decide  what  program  is  best  for  the  mal- 
nourished child.  He  is  responsible  for  the 
health  of  the  child,  and  must  have  authority 
commensurate  with  his  responsibility.  The 
teacher  and  principal  must  defer  to  his  judg- 
ment whenever  questions  arise  as  to  the  amount 
of  time  a  child  may  be  in  school  or  the  amount 
of  work  be  is  able  to  do. 

The  Nutrition  Clinic. — Each  nutrition  class 
should  have  direct  relation  with  a  nutrition,  or 
diagnostic,  clinic  where  all  cases  that  fail  to  re- 
spond to  treatment  will  be  sent  for  further  in- 
vestigation by  specialists.  An  important  func- 
tion of  the  nutrition  clinic  is  to  make  one  or 
more  special  classes  serve  as  a  clearing  house 

233 


NUTRITION  AND  GROWTH  IN  CHILDREN 

where  obscure  cases  may  be  under  observation 
for  a  sufficient  length  of  time  to  ensure  a  thor- 
ough understanding  of  their  condition. 

In  like  manner,  the  malnourished  children 
who  require  special  hours  and  additional  care 
may  be  grouped  together  in  open-air  or  special 
classes,  where  they  can  be  provided  for  without 
unduly  complicating  the  programs  of  the  nor- 
mal classes.  Children  should  not  be  placed  in 
these  special  classes  until  they  have  been  made 
''free  to  gain."  Otherwise,  there  is  danger 
that  the  classes  will  become  congested  with 
children  who  fail  to  make  progress,  and  keep 
others  from  an  opportunity  for  observation  and 
treatment. 

There  should  be  rigid  adherence  to  the  rule 
that  if  children  are  to  have  the  special  privilege 
of  open-air  schools  or  classes,  the  parents 
should  cooperate  by  having  defects  removed 
promptly  and  by  regularly  attending  the  class 
meetings  until  their  children  become  well. 

School  Hours. — It  is  easy  for  school  authori- 
ties to  forget  that  no  amount  of  education  can 
compensate  for  loss  of  health,  and  that  it 
is  better  for  a  child  to  work  part  of  the  day  in 
prime  condition  than  to  spend  double  the 
amount  of  time  dragging  over  his  lessons  in  a 
state  of  overfatigue.     On  the  other  hand,  the 

234 


MALNUTRITION  AND  THE  SCHOOL 

physician  does  not  always  remember  how  short 
a  time  many  children  are  in  school  before  they 
leave  to  go  to  work.  Nor  does  he  always  appre- 
ciate the  discouragement  that  comes  to  a  child 
when  he  falls  behind  his  grade  and  loses  step 
with  his  mates.  The  child's  day  should  be  so 
planned  that  he  may  accomplish  maximum  re- 
sults in  the  business  of  education. 

Schools  in  several  communities  are  already 
giving  credit  for  properly  conducted  rest  pe- 
riods, and  it  is  certainly  just  as  reasonable  to 
credit  rest,  when  this  is  what  the  child  needs,  as 
it  is  to  credit  gymnastic  exercise,  which  often 
overtaxes  the  child,  and,  instead  of  promoting, 
may  interfere  with,  his  growth  and  health. 

Adjustment  of  the  Schedule. — Malnourished 
children  cannot  work  profitably  upon  a  full 
school  program,  and  the  results  of  attempting 
to  do  so  may  be  serious  to  their  health.  In 
many  instances  they  can  meet  the  requirements 
up  to  the  time  of  recess,  if  they  are  then  al- 
lowed to  go  home  for  a  lunch  and  rest  period. 
This  will  bring  them  back  rested  and  refreshed 
for  the  shorter  afternoon  session.  By  a  simple 
modification  of  the  school  program  some  minor 
subject  of  study  can  be  scheduled  for  the  latter 
part  of  the  morning,  which  will  relieve  the  pres- 
sure on  all  the  pupils,  and  enable  the  malnour- 

235 


NUTRITION  AND  GROWTH  IN  CHILDREN 

ished  to  keep  up  with  their  grade  even  with  a 
temporary  absence  at  this  time. 


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Figure  36.     school  half  day 

An  Immediate  gain  was  made  by  John  B.  when  he  was  taken  out 

of  school  for  half  a  day.     Even  better  than  this  Is  the  cutting  down 

of  the  long  morning  session  by  excusing  the  child  for  a  lunch  and 

rest  period  at   10  :30.     He  can  then  return  rested  for 

the  shorter  afternoon  session. 


One-session  schedules  not  only  necessitate 
close  application  for  a  long  period  of  time,  but 
also  place  heavy  responsibilities  for  home  study 
upon  the  pupils.    They  make  it  harder  to  give 

236 


MALNUTRITION  AND  THE  SCHOOL 

cliildren  a  reasonable  program,  for  meals 
and  outdoor  life.  Nevertheless,  there  are  many- 
cities  that  keep  children  in  school  continuously 
from  8 :30  to  1 :30  or  2  :30,  with  only  20  minutes 
intermission  for  lunch. 

When  children  are  within  easy  range  of  the 
school  building,  8:45  is  a  good  opening  hour, 
and  will  allow  plenty  of  time  for  breakfast  and 
toilet  without  hurry.  At  10 :15  there  should  be 
a  20-minute  rest,  and  the  air  should  be  changed 
throughout  the  building.  At  least  an  hour  and 
a  half  should  be  allowed  for  the  noonday  meal. 
This  is  particularly  important  in  winter  in  or- 
der that  the  children  may  have  some  time  in  the 
open  air  during  the  hours  of  sunlight.  If  the 
afternoon  session  begins  at  1 :15,  there  should 
be  another  break  about  2 :30  and  school  should 
close  by  3 :30. 

This  is  a  program  for  the  normal  well  child. 
For  the  malnourished  the  schedule  after  10:15 
should  be  10  minutes  for  lunch,  15  minutes  in 
the  open  air,  and  half  an  hour  for  a  rest  period 
lying  down.  The  lunch  and  rest  periods  should 
not  interfere  with  the  child's  usual  playtime. 
Play  is  necessary  for  the  malnourished  child, 
but  should  be  supervised  to  prevent  overexer- 
tion. 

The  recess  periods  should  be  occasions  for 
237 


NUTRITION  AND  GROWTH  IN  CHILDREN 

real  recreation,  and  not  used  as  a  means  of 
punishment  or  a  time  for  additional  cramming. 
Many  children  need  fully  as  much  to  be  taught 
how  to  break  away  from  their  studies  and  get 
out  in  the  open,  as  to  study  and  recite  lessons. 
A  change  in  subject  or  classroom  is  chiefly  a 
change  from  one  form  of  pressure  to  another, 
and  does  not  provide  sufficient  relief. 

The  kindergarten  is  mainly  valuable  for  the 
opportunity  it  affords  the  child  to  sense  a  big- 
ger world  than  that  to  which  he  has  been  accus- 
tomed. Here,  too,  he  meets  the  discipline  that 
comes  from  active  contact  with  other  children 
of  his  own  age,  and  is  required  to  make  adjust- 
ments that  come  about  less  naturally  in  the  life 
of  the  home.  It  is  neither  necessary  nor  de- 
sirable that  he  should  spend  many  hours  daily 
in  this  new  environment,  and  the  child  profits 
by  a  gradual  transition  from  short  school  hours 
at  the  beginning  to  the  fairly  long  day  required 
during  adolescence. 

Adjustment  of  the  Program. — Children  should 
be  considered  as  individuals  and  not  merely  as 
members  of  a  group,  grade,  or  class.  This  is 
especially  true  of  convalescent  or  malnourished 
boys  and  girls.  Failure  to  regard  this  princi- 
ple is  responsible  for  many  of  the  misfits  and 
failures  among  children  who,  with  a  better  un- 

238 


MALNUTRITION  AND  THE  SCHOOL 

derstaiiding  of  their  individual  needs,  might  be 
trained  to  lives  of  usefulness  and  satisfaction. 

The  taste  of  success  is  necessary  to  either 
mental  or  physical  progress.  Discouraged  by 
their  inability  to  meet  the  requirements  imposed 
on  the  whole  group,  many  children  fail  to  de- 
velop the  latent  ability  they  possess,  which 
would  be  brought  out  by  tasks  suited  to  their 
capacity.  Instead  of  laying  sound  foundations 
for  the  future  years  of  effort  and  strain,  the 
school  sends  them  forth  with  a  lack  of  confi- 
dence and  a  consciousness  of  failure  which  they 
may  carry  through  life. 

Health  Education. — After  the  child  is  relieved 
of  tasks  beyond  his  strength,  and  the  school 
program  is  adjusted  on  the  basis  of  conserva- 
tion rather  than  exploitation,  there  is  still  much 
valuable  work  that  can  be  done  by  the  school 
through  the  nutrition  program.  We  hear  much 
about  ''problem"  and  "project"  work  in  the 
schools.  Where  can  one  find  problems  and  proj- 
ects that  appeal  more  directly  to  the  child  than 
those  that  have  to  do  with  bringing  himself  up 
to  normal  health,  where  he  will  be  able  to  take 
his  full  share  in  the  life  about  him,  in  its  sports 
as  well  as  its  studies! 

The  details  of  the  nutrition  class  offer  train- 
ing in  observation  and  careful  record  making. 

239 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Through  the  weekly  diet  record  a  knowledge  of 
food  values  and  food  constituents  is  gained, 
which  is  as  deserving  of  academic  credit  as 
any  other  subject  studied,  while  the  discussion 
of  food  and  health  habits  has  a  practical  educa- 
tional value  greater  than  any  abstract  course 
in  physiology  or  hygiene. 

The  nutrition  program  provides  a  check  upon 
malnutrition  from  the  time  the  child  enters 
school  to  the  end  of  his  connection  with  it.  With 
parents  informed,  instructed,  and  brought  into 
relations  of  cooperation  with  the  school  au- 
thorities from  the  start,  the  efficiency  of  the 
whole  student  body  is  raised,  and  great  waste 
and  loss  saved  to  the  community.  It  should  be 
impossible  under  this  program  to  have  such 
conditions  as  now  prevail  even  in  high  schools, 
where  from  one-third  to  one-half  the  pupils  are 
unfit  for  their  work,  worried  about  examinations 
and  promotion,  and  graduate  physically  unfit 
to  begin  their  real  work  in  life. 


CHAPTER  XXIII 

SCHOOL  LUNCHES  FOR   MALNOURISHED   CHILDREN 

School  feeding  is  no  panacea  for  malnutri- 
tion. A  common  fallacy  in  urging  tlie  estab- 
lishment of  school  lunches  is  the  belief  that  the 
problem  of  malnutrition  is  mainly  one  of  diet. 
As  already  pointed  out,  however,  only  one  of  its 
five  chief  causes  is  concerned  with  food,  and  a 
child  who  is  suffering  from  physical  defects, 
lack  of  home  control,  or  overfatigue  cannot  be 
brought  to  normal  condition  by  merely  supply- 
ing him  with  extra  food  at  school. 

It  is  as  futile  to  plan  the  school  lunch  without 
regard  to  the  other  meals  of  the  child  as  to  give 
an  infant  one  feeding  of  carefully  modified  milk 
and  allow  him  whatever  he  likes  at  other  times. 
With  due  regard  for  the  other  needs  of  the 
child,  however,  school  feeding  can  be  made  a 
useful  part  of  a  well  balanced  nutrition  pro- 
gram. There  should  be  an  extension  of  the 
school-lunch  movement  to  include  at  least  such 
simple  features  of  our  nutrition  program  as  the 
regular  weighing  and  measuring  of  the  chil- 

241 


NUTRITION  AND  GROWTH  IN  CHILDREN 

dren,  and  the  checking  of  their  diet  by  means 
of  the  48-hour  record  each  week. 

For  pupils  who  are  unable  to  go  home  for  the 
noon  meal  a  substantial  lunch  of  about  800  cal- 
ories should  be  supplied.  A  soup  or  a  hot  drink 
should  always  be  provided  during  the  winter 
months. 

A  mid-morning  lunch  of  about  300  calories  is 
needed  by  every  malnourished  child,  and  should 
be  made  available  to  all  at  cost.  Provision 
should  be  made  privately  for  indigent  children 
who  are  malnourished.  Suitable  foods  for 
these  lunches  are  thick  soup  and  crackers,  bread 
and  milk,  or  sandwiches  and  cocoa.  No  sweets 
should  be  furnished  at  this  time  as  they  tend 
to  spoil  the  appetite  for  the  next  meal. 

The  mid-morning  lunch  is  particularly  valu- 
able because  it  breaks  the  strain  of  the  long 
morning  session,  and  removes  the  sensation  of 
hunger,  which  is  apt  to  be  felt  during  the  latter 
part  of  the  morning.  As  breakfast  is  usually 
the  poorest  meal  of  the  malnourished  child,  the 
middle  of  the  morning  is  the  time  when  extra 
feeding  is  most  needed. 

As  has  been  stated,  the  child  will  assimilate 
more  food  in  five  light  meals  than  in  three  heavy 
ones.  In  fact,  various  experiments  with  chil- 
dren in  an  institution  where  full  control  was 

242 


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Figure  37.    the  value  of  lunches 

This  boy   was   nmklnff   rapid   progress   towards   his   normal   weight 

line,  when  his  mid-morning  and  mid-afternoon  lunches  were  omitted. 

The    result    was    no    gain    for    the    week,    although    his    diet    list 

showed  an  increase  in  the  total  amount  of  food  taken. 

243 


NUTRITION  AND  GROWTH  IN  CHILDREN 

possible  have  shown  that  they  gained  faster 
when  given  five  meals  a  day  of  a  lower  total 
value  than  the  customary  three  meals,  upon 
which  there  had  previously  been  no  increase  in 
weight. 

A  Comparative  Study. — In  an  experiment 
made  in  Public  School  64  in  New  York  City  ^ 
five  groups  of  children  were  studied.  Three  of 
these  followed  our  nutrition  program,  including 
a  rest  period  and  lunch  at  school  in  the  morning 
and  at  home  in  the  afternoon ;  the  fourth  group 
was  able  to  carry  out  only  part  of  the  program, 
and  the  nutrition  class  exercise  was  held  under 
adverse  circumstances ;  the  fifth  group  was  fur- 
nished a  noon  lunch  of  about  1,200  calories  daily 
with  no  other  treatment.  At  the  end  of  10  weeks 
it  was  found  that  the  fourth  group  had  made 
twice  the  gain  of  the  fifth  group,  while  the  three 
classes  that  had  followed  the  full  nutrition  pro- 
gram, but  had  not  been  supplied  with  a  noon 
meal  at  school,  did  five  times  as  well  as  the  fifth 
class  with  its  extra  feeding. 

Unfavorable  Conditions. — The  school  lunch 
has  unfortunately  been  introduced  in  many 
schools  where  an  appreciation  of  the  elements 


^"A  Nutrition  Clinic  in  a  Public  School."     (Pamphlet 
No.  1,  in  List  of  Publications,  p.  332.) 

244 


SCHOOL  LUNCHES 

of  hygiene  is  lacking.  A  dark  basement  room 
is  frequently  assigned;  the  children  have  no 
opportunity  to  wash  and  dry  their  hands  prop- 
erly; they  are  compelled  to  stand  in  line  waiting 
to  be  served;  seats  are  not  provided;  and  a 
teacher  or  janitor  hurries  them  in  their  eating 
so  that  the  room  may  be  cleared  for  other  pur- 
poses. This  friction  and  strain  result  in  fa- 
tigue, which  offsets  the  benefit  of  the  food  pro- 
vided. 

An  Educational  Opportunity. — On  the  con- 
trary, it  should  be  recognized  that  this  is  a  fav- 
orable opportunity  for  teaching  food  values  and 
proper  food  habits.  The  children  should  be 
seated,  and  allowed  ample  time  for  eating  with- 
out hurry.  They  should  have  clean  hands  and 
paper  napkins.  There  should  be  as  little  han- 
dling of  the  food  as  possible,  either  by  those 
serving  or  by  those  served.  This  is  important 
because  of  the  many  serious  diseases  that  are 
communicated  by  the  mouth.  Sandwiches  can 
be  eaten  from  the  papers  in  which  they  are 
wrapped,  and  milk  taken  through  straws  direct 
from  the  bottle. 

The  morning  lunch  should  not  be  allowed  to 
interfere  with  the  open-air  recess,  because  chil- 
dren need  a  complete  change  from  the  class- 
room conditions  at  every  intermission.     The 

245 


NUTRITION  AND  GROWTH  IN  CHILDREN 

lunch  period  should  be  a  recognized  part  of  the 
school  schedule,  and  should  be  supervised  by  a 
nutrition  worker  or  by  the  teacher  in  charge 
of  the  weekly  weighing  and  the  checking  of  the 
diet  lists.  Valuable  observations  can  be  made 
at  this  time  as  to  the  tastes,  habits,  and  re- 
actions of  the  child.  The  malnourished  chil- 
dren should  be  formed  into  groups  large  enough 
to  gain  the  benefit  of  suggestion,  comparison, 
and  competition,  but  small  enough  that  atten- 
tion may  be  given  to  each  child's  needs. 

The  complaint  is  often  heard  that  many  pu- 
pils will  not  eat  the  good  food  provided  for 
them.  These  objections  are  usually  based  on 
first  impressions.  Children  are  naturally  con- 
servative, and  are  slow  to  make  changes  in 
their  accustomed  diet,  but  the  association  with 
other  children  who  do  care  for  the  new  food 
will  soon  have  its  influence.  Reports  of  these 
lunches  are  carried  home  by  the  pupil,  and  thus 
bring  about  changes  in  the  family  diet  that  it 
would  be  difficult  to  effect  through  other 
channels. 

Obstacles  to  Progress. — In  a  model  school  in 
Chicago  where  our  nutrition  program  is  now  in 
force,  mid-morning,  noon,  and  mid-afternoon 
lunches  were  served  under  most  favorable  con- 
ditions, and  rest  periods  were  also  provided, 

246 


SCHOOL  LUNCHES 

yet  the  children  gained  the  least  of  20  similar 
groups  in  other  parts  of  the  city.  The  first 
case  investigated  was  that  of  a  girl  who  had  the 
habit  of  reading  in  bed  with  a  droplight  until 
one  or  two  o'clock  in  the  morning.  Under  such 
circumstances  no  amount  of  extra  feeding  would 
cause  her  to  gain  properly. 

The  mother  of  the  next  child  was  an  active 
member  of  the  Parent-Teacher  Association 
which  had  undertaken  the  nutrition  program. 
Her  boy  was  following  all  the  instructions  given, 
but  he  had  become  over-enthusiastic  about 
physical  training,  and  by  too  much  exercise  was 
making  worse  a  bad  condition  of  overfatigue. 

Many  of  the  children  in  this  group  either  ate 
a  very  scanty  breakfast  or  omitted  it  entirely, 
knowing  they  would  have  their  lunch  at  school 
in  the  middle  of  the  morning.  The  school  pro- 
gram in  this  case  was  ideal,  but  there  was  the 
essential  fault  that  the  program  for  the  rest 
of  the  day  was  not  controlled.  By  insisting  that 
the  parents  come  in  each  week,  thus  checking 
up  the  home  conditions  of  the  child,  such  facts 
as  those  mentioned  are  soon  brought  to  light. 

In  another  city  a  boy  whose  school  program 
had  been  lightened,  and  for  whom  rest  and  lunch 
periods  were  provided,  still  failed  to  gain  in 
weight.    It  was  some  time  before  we  found  that 

247 


NUTRITION  AND  GROWTH  IN  CHILDREN 

he  was  taking  long  swims  in  cold  water. 
Another  boy  in  the  same  class  continued  to 
drink  tea,  although  he  obeyed  all  other  direc- 
tions. Both  boys  knew  in  a  general  way  that 
what  they  were  doing  was  injurious,  and  they 
were  careful  to  conceal  the  fact  from  the  nutri- 
tion worker  until  their  own  interest  was  suffi- 
ciently aroused  to  cause  them  to  sacrifice  their 
inclinations  for  the  sake  of  good  health. 

These  cases  are  cited  to  show  that  until  the 
central  difficulty  in  each  case  was  removed,  the 
extra  feeding  failed  to  benefit  the  children.  In 
spite  of  the  difficulties  to  be  overcome,  however, 
the  school  lunch  is  nevertheless  an  important 
adjunct  of  the  nutrition  program,  and  when 
properly  served  has  great  educational  possi- 
bilities. 


CHAPTER  XXIV 

INSTITUTIONS    AND   THE   SUMMER   CAMP 

In  an  institution  where  children  are  under 
full  control  day  and  night  it  should  be  possible 
to  eliminate  malnutrition  entirely,  and  the  pres- 
ence of  a  malnourished  child  among  those  who 
have  been  in  the  institution  a  sufficient  time  for 
study  and  treatment  requires  explanation. 

The  steps  necessary  to  inaugurate  the  nutri- 
tion program  in  an  institution  are  the  same  as 
those  outlined  for  use  in  schools,  namely :  weigh- 
ing and  measuring;  complete  physical-growth 
examination  upon  entrance;  grouping  of  the 
malnourished  in  nutrition  classes;  follow-up 
work  to  make  the  children  "free  to  gain;"  ad- 
justment of  the  individual  programs  so  that 
each  schedule  will  be  suited  to  the  strength  of 
the  child. 

In  one  of  our  leading  cities  the  nutrition  pro- 
gram was  undertaken  in  two  institutions  for 
the  care  of  orphans,  which  appeal  for  support  to 
much  the  same  group  of  public-spirited  citizens. 
When  the  children  were  reexamined  six  months 
later,  it  was  found  that  one  institution  had  re- 

249 


NUTRITION  AND  GROWTH  IN  CHILDREN 

duced  its  percentage  of  malnutrition  from  22  to 
less  than  4  per  cent,  while  in  the  other  there 
had  been  practically  no  improvement. 

The  explanation  is  that  the  latter  institution 
had  applied  the  program  only  in  a  general  way, 
using  it  in  so  far  as  it  did  not  interfere  with 
the  school  schedule.  In  the  other  case  the  au- 
tho-rities  believed  that  health  is  of  more  impor- 
tance than  formal  education,  and,  consequently, 
that  education  must  bo  built  upon  health.  They 
therefore  bent  all  their  energies  toward  the  im- 
mediate end  of  bringing  their  charges  up  to 
average  weight  for  height. 

It  is  interesting  to  note  that  this  was  accom- 
plished on  an  average  daily  food  cost  of  19 
cents  per  child,  while  the  institution  that  made 
no  progress  ^vas  spending  40  cents  a  day! 

Foster  Homes. — In  another  institution  de- 
voted to  putting  children  in  condition  for  plac- 
ing in  foster  homes  an  average  of  five  physical 
defects  per  child  was  found  after  the  children 
had  been  examined  and  reported  up  to  the 
standard  required  for  school  and  other  activi- 
ties. Twenty  per  cent  of  these  boys  and  girls 
averaged  seven  or  more  defects,  and  a  group 
of  14  of  those  in  the  poorest  physical  condition 
was  put  under  care  in  a  nutrition  class.    The 

250 


INSTITUTIONS  AND  CAMPS 

defects  were  promptly  corrected,  aud  in  10 
weeks  every  child  in  the  class  was  up  to  his 
normal  weight  line. 

Usually  the  children  are  placed  in  homes  that 
do  not  receive  full  pay  for  the  care  taken,  and 
they  are  sometimes  required  to  share  in  house- 
hold tasks  or  chores  beyond  the  limits  of  their 
strength.  Most  foster  parents,  however,  have 
real  interest  in  the  children  and  can  be  depended 
upon  to  make  sacrifices  for  them  when  neces- 
sary. 

In  justice  to  this  generous  spirit  on  the  part 
of  foster  mothers  children  should  be  made 
"free  to  gain"  before  they  are  sent  out. 
They  should  be  in  condition  to  respond  to  good 
care,  and  not  suffer  from  such  handicaps  as  ob- 
structed breathing  and  other  physical  defects. 
Without  this  foresight  there  is  always  much 
illness,  many  visits  from  physicians  are  neces- 
sary, and  additional  care  from  specialists. 
This  is  discouraging  for  foster  parents  as  well 
as  for  officers  of  child-placing  institutions. 

Results  that  may  be  expected  where  chil- 
dren are  first  made  "free  to  gain"  are 
showm  in  the  record  of  a  nutrition  camp  20 
miles  out  of  the  city,  where  more  than  100  chil- 
dren from  our  nutrition  classes  were  cared  for 

251 


NUTRITION  AND  GROWTH  IN  CHILDREN 

with  but  one  medical  visit  during  a  period  of  16 
months,  and  this  visit  was  required  for  a  child 
who,  by  an  oversight,  was  admitted  to  the  home 
without  being  ''free  to  gain." 

The  foster  child's  health  is  his  only  capital, 
and  everything  possible  should  be  done  to  save 
it  from  waste  and  impairment.  The  nutrition 
program  provides  a  simple  system  for  follow- 
ing progress  by  the  report  of  his  weight  at  reg- 
ular intervals,  and  for  those  who  are  under- 
weight the  other  features  of  the  program  can 
be  applied  without  difficulty. 

Correctional  Institutions. — All  correctional 
institutions  for  children,  such  as  truant  and 
parental  schools,  should  be  so  organized  as 
to  seize  the  first  moment  a  child  comes  under 
their  control  to  look  into  his  physical  condition. 
Much  of  the  disciplinary  difficulty  with  these 
children  is  due  to  bad  physical  condition,  and 
surprising  results  in  the  way  of  improved  be- 
havior frequently  follow  the  removal  of  defects 
and  improved  nutrition. 

Summer  Camps. — Another  opportunity  for 
complete  control  over  the  child's  activities  is 
afforded  by  the  summer  camp,  which  has  the 
further  advantage  of  reaching  a  wider  range  of 
children  than  those  admitted  to  public  institu- 
tions.   Here,  again,  every  child  should  be  given 

252 


INSTITUTIONS  AND  CAMPS 

a  complete  physical  examination  and  have  his 
defects  corrected  before  leaving  home.  This 
is  the  more  important  because  camps  are  usually 
located  at  a  distance  from  the  large  centers  in 
which  specialists  are  available,  and,  if  a  child 
becomes  ill  with  such  an  affection  as  appendici- 
tis, or  an  acute  middle  ear  with  mastoiditis,  an 
emergency  operation  may  have  to  be  performed 
under  unfavorable  conditions. 

All  children  at  the  camp  should  be  weighed 
each  day,  and  the  programs  of  those  who  are 
underweight  should  be  regulated  by  their 
weight  charts.  A  boy  who  is  far  below  normal 
weight  should  be  absolutely  forbidden  to  take 
severe  physical  exercise ;  if  only  moderately  be- 
low weight,  he  should  have  supervised  exer- 
cise but  no  competition;  and  unless  fully  up  to 
weight,  he  should  not  be  turned  free  to  take 
long  hikes  or  enter  into  exhausting  contests. 

The  temptations  to  overexertion  are  nowhere 
greater  than  in  the  camp,  where  even  the  new 
idea  of  the  importance  of  health  may  lead  a 
child  to  overtax  his  strength  under  the  mis- 
taken notion  that  his  gain  will  be  in  proportion 
to  the  energy  expended.  Under  such  conditions 
overfatigue  may  bring  out  some  latent  condition 
that  will  cause  acute  illness.  Far  too  frequently 
children  come  back  from  a  summer  of  misdi- 

253 


NUTRITION  AND  GROWTH  IN  CHILDREN 

rected  camp  life  covered  with  medals  but  ' '  thin 
as  a  rail."  They  are  overtrained  and  on  edge, 
with  no  margin  of  physical  or  nervous  energy 
for  the  winter's  work. 

The  effect  of  the  various  forms  of  exercise 
upon  the  undernourished  child  should  be  care- 
fully observed.  For  example,  each  child  should 
be  inspected  after  a  swim.  If  his  reaction  is 
not  good,  his  time  in  the  water  should  be  short- 
ened, or  it  may  be  necessary  to  omit  swimming 
until  the  weight  chart,  which  is  a  sensitive  indi- 
cator of  the  effect  of  all  exercise,  begins  to 
show  a  good  gain. 

Practically  every  part  of  the  nutrition  pro- 
gram is  applicable  to  camp  life.  The  progress 
indicated  on  the  weight  chart  makes  an  excel- 
lent report  to  be  sent  each  week  to  the  parents, 
who  will  find  in  this  record  the  best  single  index 
of  the  child's  physical  and  mental  condition.  A 
boy  who  is  really  discontented  or  unhappy  soon 
shows  the  effect  in  his  weight  line,  whether  the 
fault  is  in  himself  or  in  his  surroundings. 

An  important  use  of  the  camp  has  developed 
in  the  care  of  boys  and  girls  who  fail  to  come  up 
to  the  physical  standards  required  for  employ- 
ment certificates  or  working  papers.  These 
camps  are  open  all  the  year,  and  young  people 
who  are  not  physically  fit  for  industry  are  here 

254 


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INSTITUTIONS  AND  CAMPS 

brought  up  to  weight  before  they  are  allowed 
to  seek  employment.  After  gomg  to  work  they 
are  still  kept  under  observation,  and  if  their 
employers  cooperate,  they  seldom  fail  to  con- 
tinue in  good  condition. 


CHAPTER  XXV 

MALNUTRITION   AND   THE    COMMUNITY 

Undeedevelopment,  undernourisliinent,  and 
malnutrition  are  community  problems  that 
should  be  dealt  with  in  the  same  spirit  in  which 
ignorance  and  disease  are  attacked.  Normal 
physical  and  mental  development  are  the  best 
foundations  for  a  wholesome  national  life.  In 
spite  of  the  success  which  may  attend  nutrition 
clinics  and  classes  here  and  there,  and  the  ex- 
cellent results  secured  with  individual  children 
in  private  practice,  a  nutrition  program  cannot 
be  considered  socially  effective  until  every  child 
is  brought  within  its  reach  through  the  medium 
of  a  community-wide  campaign. 

Training  in  health  is  one  of  the  most  natural 
and  valuable  means  of  education.  Instead  of 
resulting  in  self-consciousness,  as  is  sometimes 
feared,  it  is  the  best  way  to  avoid  the  dangers 
that  come  from  prejudice,  fear,  and  ignorance 
by  teaching  vital  matters  of  health  at  an  age 
when  the  habits  formed  have  permanent  effect 
on  the  development  of  the  growing  child. 

266 


MALNUTRITION  AND  THE  COMMUNITY 

Nutrition  Classes  in  the  Schools. — A  nutrition 
campaign  therefore  centers  naturally  in  the 
public  school.  The  school  organization  has  ex- 
isting machinery  through  which  to  operate  nu- 
trition classes,  and  these  classes  should  form 
an  integral  part  of  its  system  so  that  every 
child  may  be  reached.  The  person  in  charge  of 
nutrition  work  should  have  the  same  authority 
in  the  schools  that  the  medical  inspector  has  in 
the  case  of  tuberculosis  or  other  illness. 

In  addition  to  classes  in  the  schools  several 
cities  have  already  established  nutrition  camps 
for  children  who  fail  to  pass  the  physical  ex- 
amination for  employment  certificates.  Work- 
ing papers  are  withheld  until  the  children  are 
brought  up  to  normal  weight,  and  when  they 
are  considered  ready  to  enter  industry,  their 
needs  are  explained  to  the  employer  so  that 
proper  adjustments  may  be  made  to  keep  them 
in  good  condition. 

The  fundamental  preventive  work  of  the  nu- 
trition class  underlies  the  problem  of  the  asso- 
ciated charities,  the  hospital,  the  church,  the 
juvenile  court,  and,  in  fact,  all  child-helping 
organizations.  Each  of  these  agencies  can  as- 
sist in  carrjdng  out  essential  features  of  the  nu- 
trition program,  and  will  find  its  own  burden 
lessened  by  close  cooperation  on  a  unified  plan. 

257 


NUTRITION  AND  GROWTH  IN  CHILDREN 

By  discovering  aud  removing  the  causes  of 
many  diseases,  and  giving  health  instruction  to 
groups  in  schools,  the  nutrition  class  greatly 
reduces  the  number  of  children  who  need  to 
apply  to  hospitals  for  treatment.  Most  of 
the  out-patient  work  with  children  has  to  be 
done  on  Saturday  morning,  and  the  busy  phy- 
sician now  has  to  take  time  for  individual  ad- 
vice on  general  matters  of  health  that  should 
properly  be  devoted  to  careful  diagnosis.  In 
other  words,  the  out-patient  department  should 
be  a  diagnostic  clinic,  and  not  a  combination  of 
medical  and  welfare  work  with  health  instruc- 
tion. 

Nutrition  Clinics  for  Problem  Cases. — The 
distinction  between  the  nutrition  class  and  the 
nutrition  clinic  should  be  kept  in  mind.  In 
nearly  every  group  there  will  be  problem  cases 
not  solved  by  the  routine  examination  and  class 
procedure.  Obscure  s}Tnptoms  require  long 
observation  before  their  true  character  is  un- 
derstood. To  take  care  of  these  cases  there 
should  be  a  nutrition,  or  diagnostic,  clinic  in 
every  county,  in  each  of  the  smaller  cities,  and 
at  every  hospital  in  the  larger  centers,  where 
all  the  resources  of  these  institutions  can  be 
brought  into  service  when  needed. 

All  of  the  specialized  departments  for  cor- 
258 


MALNUTRITION  AND  THE  COxMMUNlTY 

rective  work  should  be  available,  but  tbe  most 
important  is  adequate  provision  for  the  removal 
of  diseased  adenoids  and  tonsils.  Even  in  our 
best  equipped  cities  children  are  scheduled 
months  ahead  for  such  operations,  and  when  a 
nutrition  class  is  organized  it  often  happens 
that  the  greater  part  of  the  first  year  is  gone 
before  it  has  been  possible  to  secure  corrective 
treatment  for  all  the  children  in  need  of  care. 

The  city  of  Rochester,  New  York,  has  enlisted 
the  interest  of  the  association  of  allied  hospitals 
in  this  work  in  cooperation  with  the  schools  and 
all  other  child-helping  organizations.  Special 
facilities  have  been  provided  to  care  for  more 
than  100  children  at  a  time  so  that  all  may  have 
adequate  rest  in  bed  following  the  operation. 
The  Rotary  Club  and  other  social  organizations 
helped,  and  the  press  kept  parents  and  friends 
so  well  informed  concerning  what  was  taking 
place  that  the  common  prejudice  against  going 
to  a  hospital  was  overcome,  and  children  were 
eager  for  their  turn.  There  were  over  1,700 
operations  on  diseased  adenoids  and  tonsils 
during  the  first  month,  and  13,372  operations 
have  been  performed  with  no  casualties. 

The  funds  for  this  work  came  from  a  ''com- 
munity chest,"  which  effectually  prevented  the 
usual  overlapping  of  boundaries  between  asso- 

259 


NUTRITION  AND  GROWTH  IN  CHILDREN 


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Figure  39.    contini^ed  gain  after  entering  industry 

Prank  M.  was  refused  a  working  certificate,  and  sent  to  tbe  Arden 
Shore  Camp  of  the  Iiiliznbelh  Mit'iuuiiik  Memorial  Ftiud,  l"liica;;o. 
Follow-up  work  secured  the  (oiipciatioti  of  his  employer,  and  he 
was  provided  with  a  Rlass  of  milk  in  the  middle  of  the  mornlu^  and 
the  middle  of  the  afternoon,  nis  chart  shows  a  pain  of  11  pounds 
iu  three  weeks  after  he  went  to  work. 

ciations,  and  the  consequent  waste  of  money, 
time,  and  energy. 

Extension    Service. — Each    state    or    connty 
should  also  have  an  oro^anized  extension  service 

260 


MALNUTRITION  AND  THE  COMMUNITY 

by  means  of  which  diagnostic  and  operating 
clinics  may  be  carried  to  communities  distant 
from  the  larger  centers.  By  the  use  of  trucks 
and  tents  all  the  essentials  of  clinic  service  can 
be  made  available  for  every  child  and  the  neces- 
sary operations  performed  without  undue  risk 
or  danger.  These  extension  facilities  are  also 
valuable  for  carrying  health  instruction  into 
outlying  communities. 

Nutrition  rallies  afford  an  excellent  means  of 
getting  into  direct  contact  with  the  parents,  and 
of  bringing  their  responsibilities  home  to  them. 
The  speakers  need  not  necessarily  be  acquainted 
with  the  technique  of  nutrition  work.  In  every 
community  there  are  men  and  women  of  ability 
who  have  broken  down  through  failure  to  recog- 
nize the  essentials  of  health.  Many  of  these 
have  worked  their  way  back  to  good  health,  and 
the  road  by  which  they  have  made  recovery  is 
a  matter  of  interest  to  others. 

The  nutrition  program  is  not  a  matter  of  con- 
cern in  regard  to  children  alone.  Parents, 
teachers,  and  other  adults  are  finding  in  it  the 
way  to  health  for  themselves.  A  thorough- 
going health  program  will  include  health  oppor- 
tunity and  education  for  all  ages.  The  out-of- 
door  contacts  of  the  Boy  and  Girl  Scouts  should 
be  so  extended  in  scope  as  to  arouse  the  interest 

261 


NUTRITION  AND  GROWTH  IN  CHILDREN 

of  all  the  members  of  the  family.  A  program 
of  this  kind  will  also  relate  itself  naturally  to 
the  provision  of  health  classes  for  adults  in 
evening  schools,  and  of  community  outing  clubs, 
camping  grounds,  golf  courses,  and  all  other 
means  of  making  it  easier  for  every  one  to  se- 
cure the  requisites  for  good  health. 

Outline  of  a  Community  Program. — In  order 
to  make  a  community  campaign  effective,  ade- 
quate preparation  is  necessary,  and  the  follow- 
ing steps  are  suggested  for  the  formation  of  one 
complete  nutrition  unit : 

First. — A  local  committee  should  be  organ- 
ized, representing  the  following  interests : 

1.  A  progressive  physician  who  knows  the  existing 
medical  agencies 

2.  A  prominent  member  of  a  child-helping  organ- 
ization having  access  to  all  branches  of  estab- 
lished welfare  work,  who  will  secure  unitj^  of 
purpose  and  cooperation  among  social  workers. 

3.  A  school  principal  or  teacher  who  appreciates 
that  education  in  health  should  be  made  an 
integral  part  of  the  school  system 

4.  An  editor  or  publicity  man  who  knows  how  to 
reach,  inform,  educate,  and  use  all  social  groups 

5.  A  banker  or  business  man  who  can  organize 
finances,  records,  etc. 

6.  A  socially  prominent  person  who  can  arouse  the 
interest  of  influential  members  of  the  com- 
munity. 

262 


MALNUTRITION  AND  THE  COMMUNITY 

Second. — Tbe  services  of  a  well-trained  nu- 
trition worker  should  be  engaged  to  organize 
and  manage  the  classes.  A  physician  thor- 
oughly interested  in  the  work  should  be  secured, 
to  be  responsible  for  the  medical  diagnoses,  for 
making  the  physical  examinations,  and  to  aid  in 
conducting  the  weekly  meetings  of  the  classes. 

Tliird. — All  supplies  and  equipment  that  will 
be  needed  should  be  secured,  including  scales, 
record  forms,  and  literature.^ 

Fourth. — A  place  should  be  provided  where 
the  classes  may  meet  regularly.  There  should 
be  a  room  for  the  physical  examinations,  and 
space  in  which  the  nutrition  worker  may  keep 
her  records  and  supplies.  Plans  should  be  made 
for  the  execution  of  the  essential  features  of  the 
program,  such  as  the  place  and  time  for  rest 
periods  and  lunches ;  conferences  with  parents ; 
visits  to  homes;  cooperation  with  the  school 
principal,  teachers,  nurses,  and  physicians. 

Fifth. — The  children  in  one  school,  or  at  least 
a  group  of  300,  should  be  weighed  and  meas- 
ured. Among  this  number  there  will  be  from 
60  to  100  who  are  at  least  seven  per  cent  under- 
weight for  their  height  and  in  need  of  treat- 
ment.   One  nutrition  worker  will  be  able  to  care 


^  See  List  of  Publications,  p.  331. 
263 


NUTRITION  AND  GROWTH  IN  CHILDREN 

for  about  100  children,  and  five  classes  should 
be  formed  from  this  number. 

Sixth. — The  movement  should  be  advertised 
by  ample  publicity.  Poster  competitions  and 
other  contests  in  the  schools  will  interest  the 
children.  Speakers  on  the  programs  of  local 
and  state  meetings  of  educational,  social,  med- 
ical, and  labor  organizations,  and  articles  in  all 
the  local  papers,  will  help  to  arouse  the  public. 
The  committee  should  keep  in  touch  with  the 
women's  clubs,  parent-teacher  associations,  and 
similar  organizations.  The  public  library 
should  be  asked  to  supply  books  and  periodicals 
on  nutrition,  and  to  feature  them  on  its  bul- 
letin board. 

Seventh. — Records  should  be  carefully  kept. 
The  various  forms  and  blanks  printed  in 
the  appendix  are  the  result  of  long  experience, 
and  should  be  thoroughly  understood.  These 
records  are  important,  not  only  to  show  what  is 
accomplished  locally,  but  as  data  that  may  aid 
in  extending  the  scope  of  the  work  and  help  in 
solving  difficult  problems  elsewhere. 

Eighth. — The  main  purpose  should  be  kept  in 
mind.  The  committee  should  keep  in  touch 
with  all  indications  of  interest  in  community 
health;  secure  exact  knowledge  about  medical 
inspection  in  the  schools  and  the  examination 

264 


MALXUTEITION  AND  THE  COMMUNITY 

of  candidates  for  working  papers;  follow  up 
plans  for  summer  outings,  aids  for  convales- 
cents and  for  cases  of  special  need;  keep  posted 
on  the  teaching  of  hygiene,  food  values,  physical 
training,  etc.  Nevertheless,  all  these  things 
must  be  considered  in  relation  to  the  central 
purpose  for  which  the  nutrition  unit  has  been 
organized,  that  of  health  education  and  of  re- 
storing malnourished  children  to  normal  stand- 
ards of  growth. 


CHAPTER  XXVI 

MALNUTRITION   AND    TUBERCULOSIS 

The  problem  of  tuberculosis  is  the  problem 
of  nutrition.  Malnutrition  in  children  usually 
illustrates  either  failure  or  neglect  on  the  part 
of  the  physician:  failure,  because  the  condi- 
tion is  rarely  diagnosed;  neglect,  because  he 
does  not  take  time  to  get  at  the  real  condition 
and  its  causes.  The  fact  that  it  'has  not  been 
recognized  as  a  medical  diagnosis  makes  the 
malnourished  child  an  easy  prey  to  tuberculosis 
and  other  diseases.  An  undernourished  body 
is  the  best  possible  culture  ground  for  tubercle 
hacilli. 

Malnutrition  is  common  among  families  in 
which  tuberculosis  is  present,  but  instead  of 
giving  the  malnourished  child  special  care  be- 
cause of  his  lowered  resistance,  the  physician's 
attention  is  frequently  so  fixed  upon  the  tu- 
bercular process  itself  that  he  takes  little  heed 
of  the  child's  actual  condition  in  other  respects. 
Furthermore,  the  nurses  in  charge  of  such  fami- 
lies have  been  trained  in  the  care  of  bed  pa- 
tients, and  seldom  understand  what  to  do  for 

266 


MALNUTRITION  AND  TUBERCULOSIS 

these  children  until  they  are  so  ill  as  to  be 
beyond  help. 

The  five  chief  causes  of  malnutrition  are 
strikingly  evident  in  families  suffering  from 
tuberculosis.  Uncorrected  physical  defects  are 
more  frequently  found  here  than  elsewhere. 
In  one  large  group  of  such  children  in  Boston, 
50  per  cent  were  in  urgent  need  of  operations 
to  remove  diseased  adenoids  and  tonsils,  after 
having  been  under  treatment,  in  some  cases  for 
years,  in  a  tuberculosis  clinic. 

The  second  of  these  causes  is  lack  of  home 
control,  and  in  no  other  group  have  we  found 
so  many  seriously  disorganized  homes.  In  long 
illness  the  mother's  care  is  concentrated  upon 
the  sick  person,  and  her  attention  is  diverted 
from  the  other  members  of  the  family,  which 
tends  to  break  up  those  habits  of  regularity  and 
order  upon  which  successful  home  life  depends. 
When  the  sick  member  is  taken  away  for  treat- 
ment, the  family  is  sometimes  broken  up  tem- 
porarily, and  when  the  mother  gets  her  little 
flock  together  once  more  the  old  unity  is  gone, 
and  it  is  difficult  to  reestablish  the  influence  of 
family  habits  and  customs. 

It  is  better  policy  wherever  possible  to  keep 
the  family  together  and  to  take  care  of  the  pa- 
tient at  home.    It  should  be  recognized  that  only 

267 


NUTRITION  AND  GROWTH  IN  CHILDREN 

in  pulmonary  tuberculosis  is  there  serious  dan- 
ger of  communication  of  the  disease,  and  the 
treatment  prescribed  for  the  victim  of  tubercu- 
losis is  also  desirable  for  those  who  are  well. 
Open  air,  ample  nourishment  and  rest,  as  ad- 
vised for  the  tuberculosis  patient,  will  increase 
the  resistance  of  the  other  members  of  the  fam- 
ily. When  a  cure  is  effected  in  the  patient's 
o\\Ti  home,  new  habits  are  established  that  tend 
to  make  the  results  permanent. 

Overfatigue  is  a  constant  factor  in  tubercu- 
losis. In  one  of  our  classes  there  was  a  girl  of 
14  who  had  spent  some  time  in  a  tuberculosis 
sanitarium.  She  was  one  of  9  children,  and  was 
found  by  the  nutrition  worker  to  be  doing  most 
of  the  housework,  including  the  washing.  As 
an  older  sister  required  the  only  good  room  for 
callers  in  the  evening,  this  girl  and  a  younger 
sister,  also  an  incipient  case,  had  to  sleep  in  a 
small  dingy  room  on  a  court.  The  family  had 
pie  for  breakfast,  and  tea  or  coffee  at  every 
meal.  The  mother  seemed  thoroughly  indiffer- 
ent; all  the  children  suffered  from  pediculosis. 

This  girl  was  five  grades  behind  her  age  in 
school,  and  her  teacher  applied  all  possible 
force  to  hold  her  up  to  the  requirements.  This 
involved  staying  after  school,  home  work  under 
unfavorable  conditions,  and  when  she  was  un- 

268 


MALNUTRITION  AND  TUBERCULOSIS 

able  to  keep  up  even  under  this  pressure,  she 
was  sentenced  to  a  term  at  the  summer  session 
of  the  vacation  schooL  As  it  was  impossible  to 
persuade  the  school  authorities  to  give  her  a 
reduced  schedule,  she  had  to  be  taken  out  of 
school  entirely  and  sent  to  the  country  to  re- 
cuperate. Here  she  was  free  from  overfatigue, 
and  gained  seven  pounds  in  four  weeks.  Dur- 
ing her  absence  the  mother's  pride  was  awak- 
ened, and  the  home  organization  changed  so 
that  it  soon  ranked  the  best  among  50  families 
then  under  observation.  In  30  weeks  on  the 
nutrition  program  this  child  gained  435  per 
cent  of  the  expected  rate  of  gain  in  weight  for 
her  age. 

Another  girl  in  the  same  nutrition  class  had 
more  favorable  home  conditions,  but  was  under 
constant  strain  because  her  brightness  and  at- 
tractiveness led  to  exploitation  by  school  and 
social  agencies.  She  was  the  leading  figure  in 
all  school  plays,  attended  club  meetings  at 
neighboring*  settlements  four  days  each  week, 
had  a  piano  lesson  on  Saturday  morning,  and, 
as  chief  entertainer,  danced  frequently  at  wed- 
dings in  the  homes  of  friends  and  neighbors. 
When  her  mother  was  made  to  understand  the 
meaning  of  this  overfatigue,  which  made  the 
child  "too  tired  to  eat,"  and  was  rendering  her 

269 


NUTRITION  AND  GROWTH  IN  CHILDREN 

specially  susceptible  to  tuberculosis,  her  whole 
program  was  changed,  and  she  was  soon  up  to 
normal  weight. 

Fifty  per  cent  of  this  class,  which  was  com- 
posed of  children  who  were  suspected  of  being 
tuberculous  or  had  been  directly  exposed  to 
tuberculosis — were  doing  extra  tasks  outside  of 
school  hours.  There  were  music  and  language 
lessons,  club  meetings,  and  various  forms  of 
"gainful  occupation."  Sixty-four  per  cent 
kept  late  hours.  Much  of  this  was  easily  cor- 
rected, but  there  were  too  many  cases  like  that 
of  a  girl  of  eleven,  15  per  cent  underweight  and 
very  delicate,  who  was  studying  every  night 
until  after  11  o'clock — on  the  waiting  list  of  a 
sanitarium,  yet  compelled  to  carry  out  a  school 
program  too  heavy  for  even  a  well  child ! 

The  next  cause  of  malnutrition  enumerated — 
improper  diet  with  faulty  food  habits — is  also 
of  special  importance  in  tuberculosis.  The  ab- 
normal conditions  of  long  illness  lead  to  irregu- 
larity in  eating  and  a  disregard  of  fundamental 
requirements.  Attention  is  often  so  completely 
focused  upon  supplying  the  food  needs  of  the 
sick  person  that  the  other  members  of  the  fam- 
ily are  neglected.  In  the  group  studied  28  per 
cent  were  not  taking  sufficient  food,  not  because 
there  was  not  enough  available  but  because  of 

270 


MALNUTRITION  AND  TUBERCULOSIS 

faulty  food  habits.  Thirty-six  per  cent  were 
habitually  fast  eaters. 

The  fifth  cause  of  malnutrition — faulty  health 
habits — is  bound  up  with  the  others  already  dis- 
cussed. In  the  class  above  mentioned,  funda- 
mental health  needs  were  overlooked  even 
where  children  were  under  treatment,  and  the 
families  given  aid.  Exercise  and  play  in  the 
open  air  and  sunlight  had  a  very  small  part  in 
these  children's  lives,  and  they  were  allowed  to 
sleep  under  conditions  that  destroyed  the  good 
effect  of  all  the  help  given. 

The  care  of  these  so-called  ^'pre-tubercular" 
children  should  be  part  of  a  "Physically  Fit" 
campaign  in  which  all  organizations  interested 
in  children  should  be  brought  into  association. 
When  the  attempts  to  aid  these  families  are  cen- 
tered in  a  specially  labeled  tuberculosis  clinic, 
the  children  suffer  from  the  stigma  of  being 
called  ''pip"  cases  by  their  companions. 

Public  money  should  no  longer  be  spent 
with  one  hand  to  make  well  children  sick  and 
sick  children  worse  through  overfatigue  at 
school,  while  the  other  makes  appropriations 
for  sanitaria  to  make  them  well.  Every  child 
applying  for  entrance  to  the  public  school 
should  be  examined  in  the  presence  of  his  par- 
ents and  required  to  be  up  to  normal  weight 

271 


NUTRITION  AND  GROWTH  IN  CHILDREN 

before  he  is  allowed  to  assume  the  burden  of 
full  school  work.  Settlements  and  other  social 
organizations,  while  continuing  the  good  work 
they  are  doing,  should  not  leave  undone  the  duty 
to  see  that  the  children  are  in  condition  to  profit 
by  what  is  offered  them.  Health  crusades 
should  not  give  highest  honors  to  athletic 
achievement  without  knowing  whether  it  is  rest 
or  activity  that  is  most  needed  for  proper  devel- 
opment in  each  individual  case.  Boy  and  Girl 
Scouts  should  put  the  emphasis  on  growth  and 
health  by  requiring  as  a  first  step  in  the  prog- 
ress of  the  "tenderfoot"  that  he  have  a  body 
weight  sufficient  to  sustain  his  height.  The 
elimination  of  malnutrition  from  any  com- 
munity is  its  greatest  safeguard  against  tu- 
berculosis. 


CHAPTER  XXVII 

MALNUTRITION   AND   PREVENTIVE    MEDICINE 

No  branch  of  medical  science  promises  so 
much  for  the  future  as  preventive  medicine. 
Dramatic  operative  procedure,  intravenous  and 
intraspinal  medication  mark  wonderful  ad- 
vances in  saving  life,  but  how  much  farther  we 
shall  have  progressed  when  the  need  for  such 
extreme  measures  has  been  prevented  as  far  as 
possible. 

More  than  one-half  of  the  diseases  of  child- 
hood, including  meningitis  and  scarlet  fever, 
are  preventable,  and  the  length  of  human  life 
could  be  increased  one-third  were  the  existing 
knowledge  of  hygiene  universally  applied.^  It 
is  estimated  that  at  least  one-half  of  the  3,000,- 
000  or  more  sick  beds  constantly  filled  in  the 
United  States  would  be  unnecessary,  and  over 
600,000  yearly  deaths  might  be  prevented,  if 
such  preventive  measures  as  are  entirely  practi- 
cable were  promptly  undertaken.    The  annual 

■»  Irvitii?  Fisher,  "Economic  Aspects  of  Lengthening  Hu- 
man Life." 

273 


NUTRITION  AND  GROWTH  IN  CHILDREN 

loss  in  earnings  cut  off  by  these  preventable 
diseases  and  premature  deaths  reaches  the 
stupendous  sum  of  $1,500,000,000.^ 

Such  estimates  do  not  consider  the  lowered 
efficiency  of  countless  other  persons  who  go 
through  life  in  a  state  of  partial  invalidism — • 
those  who  never  know  what  it  is  to  be  really 
well. 

The  Nutritian  Program  and  Prevention. — The 
first  step  in  prevention  is  to  establish  good  nu- 
trition and  health  in  the  infant,  which  is  at  once 
reflected  in  lowered  mortality  rates.  Milk  sta- 
tions in  our  crowded  cities  have  demonstrated 
that  one  nurse  can  safely  carry  75  to  100  babies 
through  a  hot  summer,  not  only  keeping  them 
free  from  serious  illness  but  actually  gaining  in 
weight,  by  intelligent  supervision  and  weekly 
weighings. 

If  the  same  supervision  and  care,  with 
monthly  weighings,  were  carried  through  the 
entire  period  of  growth,  it  requires  little  im- 
agination to  see  what  an  immense  saving  of 
time  and  expense  would  result,  as  well  as  the 
prevention  of  mjDst  of  the  diseases  and  deformi- 
ties treated  at  the  hospitals.  This  is  what  we 
propose  in  our  nutrition  program,  utilizing  the 


2  Fisher  and  Fisk,  "How  to  Live." 
274 


PREVENTIVE  MEDICINE 

school  organization  that  all  children  may  be 
reached. 

One  of  the  first  indications  of  disease  is  loss 
of  weight,  and  it  is  in  the  underweight  group 
that  most  cases  of  serious  illness  arise.  Just  as 
the  malnourished  child,  because  of  his  low  re- 
sistance, falls  an  easy  prey  to  tuberculosis,  so 
also  he  readily  succumbs  to  other  infections. 
It  has  been  demonstrated  in  our  classes  repeat- 
edly that  when  a  child  who  is  severely  under- 
weight contracts  an  illness,  as  during  a  mild 
epidemic  of  scarlet  fever,  he  falls  a  victim  to 
the  disease  almost  without  a  struggle. 

In  one  instance,  the  mother  of  a  bright  and 
precocious  boy  was  unwilling  to  have  him  omit 
violin  lessons,  which,  in  addition  to  his  school 
work,  were  clearly  causing  overfatigue.  Two 
weeks  later  the  boy  succumbed  to  an  acute  ill- 
ness, and  the  mother  returned  to  the  clinic  to 
inquire  pathetically  if  we  thought  her  boy 
would  have  lived  if  his  violin  lessons  had  been 
stopped. 

The  mere  weighing  and  measuring  of  a  group 
of  children  marks  an  initial  step  in  the  preven- 
tion of  disease.  In  one  community  the  under- 
weight children  showed  in  10  weeks'  time  61  per 
cent  more  than  the  average  gain  of  well  chil- 
dren, following  no  other  application  of  the  nu- 

275 


NUTRITION  AND  GROWTH  IN  CHILDREN 

trition  program  beyond  the  weighing  and  meas- 
uring. 

The  fact  that  so  many  children  are  found  to 
be  below  the  average  weight  for  their  height 
should  be  a  challenge  to  all  the  forces  concerned 
in  safeguarding  their  health.  In  the  nutrition 
program  the  complete  physical-growth  exami- 
nation, following  immediately  after  the  w^eigh- 
ing  and  measuring,  is  an  important  step  in  pre- 
vTention  by  disclosing  the  causes  of  the  child's 
malnutrition.  The  early  removal  of  these 
causes  saves  immeasurable  suffering  and  loss  of 
life. 

How  much  better  it  is,  for  example,  to  re- 
move infected  tonsils  before  the  inflammatory 
process  has  left  permanent  marks  upon  the 
child's  development,  or  led  to  complications 
arising  from  the  spread  of  the  infection  to  vital 
organs  of  the  body.  The  diagram  on  page  277 
illustrates  how  the  early  discovery  and  removal 
of  the  causes  of  malnutrition  may  prevent  re- 
sults that  are  taxing  to  the  utmost  our  hospitals 
and  other  institutions. 

Effect  of  Wrong  Ideas. — It  would  be  inter- 
esting if  we  were  able  to  measure  the  effect  of 
wrong  ideas  upon  the  health  of  the  community. 
A  fear  of  disease  arising  from  the  manifesta- 
tion of  normal  processes  has  an  effect  upon  the 

276 


PREVENTIVE  MEDICINE 


Common  Defects  and  Results  of  Neglect 


Early  Diagnosis  and  Preven- 
tive Work  in  Nutrition 
Classes  in  the  School 


Naso-pharyngeal  obstruction " 


Postural  defects 


Eye  strain 


Teeth  defects 


Poor  hygiene,  etc. 
Tea  and  coffee  habits 


Early  appendicitis 


Malnutrition 


Late  Diagnosis  and  Corrective 
Work  in  Out-patient  Depart- 
ments and  Hospital  Wards 

Otitis  media 

Deafness 

Mastoiditis 

Sinus  infection 

Cardiac  disease 

Joint  infections 

Nephritis 

Pyelitis 

Asthma 

Emphysema 

Fatigue  posture 

Flat  foot 

Spinal  curvature 

Round  shoulders 

Visceroptosis 

Impaired  vision 

Headache 

Fatigue 

Carious  teeth 

Antrum  infection 

Alveolar  abscess 

Malocclusion 

Deformities  of  face  and  jaw 

Anemia 

Acne 

Eczema 

Pediculosis 

Intestinal  parasites 

Gastritis  and  intestinal  indiges- 
tion 

Disturbance  of  the  nervous  sys- 
tem 

Fulminating  appendicitis 

Peritonitis 

Intestinal  adhesions 

Tuberculosis 

Syphilis 

Lowered  resistance  to  infection 

Postural  defects 

Early  senility 

Impaired  race 


277 


NUTRITION  AND  GROWTH  IN  CHILDREN 

whole  after  life  of  the  individual.  A  mistaken 
impression  about  drafts  or  night  air  may  lead  to 
faulty  health  habits  with  serious  consequences. 
An  early  prejudice  against  resting  in  the  day- 
time is  often  responsible  for  overfatigue,  which 
leads  in  time  to  a  totally  unnecessary  break- 
down. A  wrong  idea  of  some  particular  rela- 
tion of  cause  and  effect  may  lead  one  to  put  his 
trust  in  some  nostrum,  superstition,  or  cult. 

Many  erroneous  notions  on  the  part  of  both 
parents  and  children  come  out  in  the  class  meet- 
ing and  in  other  phases  of  the  nutrition  pro- 
gram. For  example,  one  mother  was  omitting 
cereal  from  a  child's  diet  in  the  summer  be- 
cause she  thought  oatmeal  was  heating ;  another 
tried  to  build  up  her  undernourished  child  on 
beef  tea,  which  she  thought  particularly  nour- 
ishing; a  boy  who  was  seriously  underweight 
was  trying  to  keep  his  weight  down  by  under- 
feeding because  he  thought  if  he  became  fat  he 
could  never  be  an  athlete;  another  boy  failed 
to  eat  sufficient  food  for  fear  of  appendicitis; 
another  stayed  up  late  at  night  because  he 
thought  there  was  no  need  to  go  to  bed  unless 
he  could  fall  asleep  immediately. 

During  the  campaign  to  secure  money  for  the 
suffering  children  in  Europe,  the  principal  of 
a  high  school  in  a  large  city  proposed  to  the 

278 


PREVENTIVE  MEDICINE 

pupils  that  they  go  without  lunches  every  other 
day  and  put  the  money  into  the  relief  fund. 
This  unwise  proposition  was  accepted  with  en- 
thusiasm by  the  pupils  and  applauded  by  the 
newspapers  throughout  the  country  because  no 
one  seemed  to  appreciate  the  anomaly  of  under- 
feeding growing  children  here  in  order  to  re- 
lieve the  distress  resulting  from  the  same  cause 
abroad. 

Health  Education  and  Prevention. — Preven- 
tive medicine  should  include  such  instruction  as 
will  eradicate  these  false  ideas  before  they  be- 
come fixed,  and  bring  matters  pertaining  to 
health  clearly  over  into  the  regions  controlled 
by  sound  experience  and  common  sense.  The 
surest  safeguard  against  these  unreasonable  yet 
powerful  influences  is  a  fund  of  knowledge  con- 
cerning the  essentials  of  growth  and  health. 

Discriminating  consideration  for  one's  own 
physical  condition  leads  away  from  morbid  self- 
analysis.  It  is  the  person  lacking  the  essential 
knowledge  and  the  trained  executive  ability  to 
keep  himself  fit  who  falls  a  victim  to  hypo- 
chondriacal ideas.  It  is  important  to  use  every 
means  of  discovering  such  insidious  ideas  and 
overcoming  the  habits  that  grow  out  of  them. 

In  the  prevention  of  sickness  we  have  an  op- 
portunity for  health  education  of  the  highest 

279 


NUTRITION  AND  GROWTH  IN  CHILDREN 

order,  A  child  should  be  as  thoroughly  drilled 
ill  the  essentials  of  health  as  in  the  principles  of 
arithmetic  or  language. 

Infection  is  an  invasion  of  organisms  which 
threaten  life,  and  must  be  met  by  leucocytes 
from  the  blood.  A  battle  is  fought  between 
them  as  real  as  that  of  armies,  and  the  stronger 
wins.  Preparedness  is  more  necessary  in  the 
life  of  the  child  than  in  that  of  the  nation,  be- 
cause, while  the  occasion  for  actual  warfare 
may  not  arise,  there  is  no  escape  from  the 
child's  risk  of  infection  from  the  destructive 
organisms,  which  are  constantly  present  as 
though  waiting  for  a  favorable  opportunity  to 
attack. 

Davidsohn  reports  ^  that  in  Berlin  there  was 
a  marked  increase  of  tuberculosis  infection  in 
children  during  the  war,  48  deaths  per  10,000 
of  the  population  occurring  in  1919,  as  com- 
pared with  32  in  the  year  before  the  war.  The 
European  epidemics  which  caused  a  high  mor- 
tality during  this  period  also  show  a  distinct 
relationship  between  malnutrition  and  the 
prevalence  of  infection. 

The  best  insurance  that  a  child  has  against 

^  H.  Davidsohn,  "Die  Wirkuns:  der  Aushiingerung 
Deutsclilands  auf  die  Berliner  Kinder,"  Zeitschrift  fur 
Kinderkrankheiten,  21:349,  1919. 

280 


PREVENTIVE  MEDICINE 

sickness  is  not  necessarily  the  most  healthful 
surroundings,  but  a  sound  body  to  resist  dis- 
ease. Ideal  surroundings  are  not  always  avail- 
able for  every  child,  but  our  nutrition  classes 
have  shown  that  it  is  possible  to  establish  a 
sound  body  in  almost  any  environment.  Health 
once  established  in  the  growing  period  by 
health  education  will,  as  a  rule,  continue 
throughout  life.  Health  and  education  should 
go  hand  in  hand — health  in  education  and  edu- 
cation in  health. 


CHAPTER  XXVIII 

THE  EXTENT  OF  MALNUTRITION  AND   SOME   RESULTS  OF 
NUTRITION    WORK 

The  most  reliable  evidence  of  the  extent  of 
malnutrition  is  secured  by  weighing  and  meas- 
uring groups  of  children  in  various  localities 
representing  family  circumstances  of  wide  va- 
riety. In  this  chapter  statistics  are  presented 
in  Table  VII  that  answer  the  questions  so  often 
asked,  "How  much  malnutrition  is  found  in 
representative  American  communities?"  and 
*'Is  not  malnutrition  largely  confined  to  the 
poor?" 

Since  the  best  record  of  progress  in  regain- 
ing health  appears  in  the  weight  chart,  we  are 
also  giving  figures  in  Table  VIII  that  show  the 
gains  made  in  similarly  varied  communities 
where  our  nutrition  program  has  been  carried 
out. 

We  have  collected  a  large  amount  of  data 
wiiich  have  been  secured  by  schools,  medical  au- 
thorities, and  others  with  reference  to  the  ex- 
tent of  malnutrition  in  Europe  and  America, 
but  because  of  the  lack  of  a  single  objective 

282 


EXTENT  OF  MALNUTRITION 

standard  on  the  part  of  the  examiners,  the  wide 
range  of  individual  differences  makes  the 
greater  part  of  this  material  of  little  value  for 
purposes  of  comparison.  Thousands  of  chil- 
dren have  been  weighed  and  measured,  how- 
ever, during  the  last  few  years  according  to  the 
methods  outlined  in  this  book,  and  the  record 
thus  secured  may  be  taken  as  reliable  evidence 
of  the  prevalence  of  malnutrition  in  this  coun- 
try. These  figures  are  given  in  Table  VII  on 
the  following  pages. 

It  will  be  observed  that  these  statistics  have 
been  gathered  in  a  territory  ranging  from  At- 
lanta to  Boston,  New  York,  and  Chicago  in  the 
United  States,  and  extending  into  Canada  and 
Labrador  in  the  British  possessions.  The  out- 
standing facts  in  the  table  are  the  wide  extent 
of  malnutrition  in  all  sections  entered  and  its 
striking  prevalence  in  all  classes  of  society. 
Wlierever  comparison  has  been  made,  it  has 
been  found  that  the  proportion  among  the  so- 
called  "better  classes"  is  as  great  or  even 
greater  than  among  the  poorer  and  immigrant 
groups. 

In  the  early  stages  of  our  work  with  mal- 
nourished children  we  gave  them  the  best  pos- 
sible care  according  to  our  knowledge  at 
that  time,  increasing  the  amount  of  food,  im- 

283 


NUTRITION  AND  GROWTH  IN  CHILDREN 
Table  VII.     Extent  of  Malnutrition 


Number  of 
Cases  • 

Percentage   of   Malnutrition 

Locality 

Borderline 
Under- 
weight 

less  than  7 
Per  Cent 

Under- 
weight 

7  Per 
Cent  or 

More 

Under- 
weight 
10  Per 
Cent  or 
More 

Atlanta,   Georgia : 

Country  Hiffli  School.. 

49 
73 

14 

12 

9 

53 
62 
54 

52 
18 

Girls'   High  School 

Elementary  grades   .  .  . 

Open  air  school  

Home  of  the  Friendless 

42 
74 

245 

5.045 
1,710 

27 

Boston : 

Little  Wanderers'  Home 

27 

Chicago : 

10  public  schools,  1919 
3  public  schools,  1921 

25 
40 

30 
28 
27 
31 
20 
28 
84 
30 
31 
27 
22 
18 

40.5 
85.5 

20 
24 

25 
32 
28 
31 
40 
32 
38 
17 
21 
19 
36 
27 
25 
36 
28 
46 

27 
17 
22 

20 
27 
22 

26 
29 

61 

25 

John      Marshall     High 
School    

Parker  High   School    . . 

Francis       W.       Parker 
School   (private) 

Girls              

Grade   t     

Grade  IT 

Grade  III 

Grade  IV 

Grade  V 

Grade  VI 

Grade  A^II 

Grade  VIII 

Parochial  school   

United   Charities  group 
Mothers'  Pension  group 

350 
450  ' 

33 

88 
31 

37 
13 
14 

14 
21 
23 

23 
29 

Open     window     school 

Sicilian   poor  group    . . 
Italian  poor  group    .  .  . 
Foreign      group      (mis- 
cellaneous)     

Poor    district     

Poor    district     

Moderate  circumstances 

1.20R 
262 

256 

7S2 
726 

653 
212 

Well-to-do  group 

South     Side    well-to-do 

•  Whenever  small  groups  are  given,  they  represent  the  entire 
membership  of  certain  classes,  and  in  no  case  have  the  figures  been 
Influenced  by  ispecial  selection. 

284 


EXTENT  OF  MALNUTRITION 
Table  VII.     Extent  of  Malnutrition — Continued 


Number  of 
Cases 

Percentage    of    Malnutrition 

Locality 

Borderline 
Under- 
weight 
less  than  7 
Per  Cent 

Under- 
weight 
7  Per 
Cent  or 
More 

Under- 
weight 
10  Per 
Cent  or 
More 

Dayton,    Ohio  : 

Public  school   

246 

312 
360 
202 

492 

251 
76 
61 

104 

894 
255 
127 
245 
173 
25 

69 

401 

40 

21 
21 
36 

25 

32 
21 
23 
13 

18 
17 
21 
16 

14 
28 

28 

26 
23 
36 

42 
34 
60 
37 
29 

28 
58 
54 
29 

Illinois: 

School      for      Soldiers' 
Orphans    

19 
19 

24 

School  for   Deaf    

School  for  Blind 

Manchester,  N.  H. :  "^^ 
Total   survey  : 

Three     "l)etter     class" 
schools    

Greek    group    

Polish   group    

French-Canadian  group 

New   York    City  : 

Public  School  64   (East 
Side)    

Grade  I     

Grade  V    

Grade  VI    

Grade  VII    . . . 

Open   air   class    .... 
Specials    ("exception- 
ally bright")    

Rochester,  N.  Y. : 

Immigrant    poor    group 

St.  Anthony,  Labrador : 
Total   survey  : 
Orphanage    

191 
41 
63 
52 
35 

241 
714 
670 

882 

Village    

Harbour    

Bight     

Toronto,    Canada  : 

York  School   (Russians, 
Poles,    Italians,    Cbi- 

14 

Dnfferin  School 

35 

Withrow    School    

34 
14 

285 


NUTRITION  AND  GROWTH  IN  CHILDREN 
Table  VII.     Extent  of  Malnutrition — Continued 


Number  of 
Cases 

Percentage    of    Mai 

nutrition 

Locality 

Borderline 
Under- 
weight 
less  than  7 
Per  Cent 

Under- 
weight 
7  Per 
Cent  or 

More 

Under- 
weight 
10  Per 
Cent  or 
More 

Walpole,  Mass. :  t 

Public  schools    

1,305 

19 
15 
22 
21 
22 
19 
22 
20 
22 
18 
11 
10 
20 
6 

22 
20 
20 

10 
14 
12 

20 
18 
19 

36 
30 
37 
35 
40 
37 
44 
43 
35 
43 
25 
29 
15 
29 

34 
43 
39 

25 
23 
24 

33 
39 
36 

Grade  I         

Grade  II 

Grade  III   

Grade  IV        .... 

Grade  V 

Grade  VI 

Grade  VII    . .    . . 

Grade  VIII 

Grade  IX    

Grade  X   

Grade  XI    

Grade  XII    

Elementary  grades 

Girls    

Both  sexes    

High    School : 

Bovs    

Girls    

Both  sexes    

All  grades : 

Boys    

Girls     

t  DiSTRIBDTION    OF    MaLNDTEITION     IN    WALPOLE    ACCDKDIXG    TO 

Pekcentagb  Undeuweight 


Underweight 

Cases 

Underweight 

Cases 

Per  Cent 

Per  Cent 

Per  Cent 

Per  Cent 

1 

.8 

12 

2.6 

2 

1.3 

13 

2.2 

3 

3.4 

14 

1.4 

4 

4 

15 

1.5 

5 

4.5 

16 

.6 

6 

5 

17 

1.2 

7 

5.3 

18 

.6 

8 

5.5 

19 

.6 

9 

4 

20 

.8 

10 

6.1 

21 

0 

11 

3.3 

22 

.3 

286 


EXTENT  OF  MALNUTRITION 

Table  VII.     Extent  of  Malnutrition — Continued 


Number  of 
Cases 

Percentage  of  Malnutrition 

Locality 

Under- 
weight 
Borderline 
less  than" 
Per  Cent 

Under- 
weight 

7  Per 
Cent  or 

More 

Under- 
weight 
10  Per 
Cent  or 
More 

Washington,  D.  C. : 
Total  survey    

3,913 

29.5 

White    

36 

Colored    

26.3 

Kindergarten    

22.7 

Grade  I     

28.8 

Grade  II     

24.8 

Grade  III    

27.9 

Grade  IV    

25.8 

Grade  V    

30.7 

Grade  VI    

33  9 

Grade  VII     

33  7 

Grade  VIII     

34.3 

Willlamstown,  Mass. : 
Total   survey 

443 

240 
203 

30.6 

Boys  5  to  14  years. 

26.6 

Girls  5  to  15 

35 

proving  the  sleeping  conditions,  and  correcting 
other  matters  of  general  hygiene.  The  result 
was  that  the  few  children  who  needed  only  these 
simple  adjustments  came  up  to  normal  weight 
promptly,  but  the  majority  persisted  in  making 
either  very  slight  gains  or  none  at  all.  The 
chart  given  in  Figure  40  reports  a  typical  case 
of  this  period. 

Despite  such  convincing  records,  efforts  are 
still  made  to  do  away  with  malnutrition  by  giv- 
ing attention  principally  to  a  single  factor  such 
as  diet.    Figure  41  gives  the  recently  published 


287 


NUTRITION  AND  GROWTH  IN  CHILDREN 

results  ^  of  classes  conducted  under  the  most 
modern  principles  of  dietary  efficiency  as  com- 


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FiGUBE   40.      AN   EARLY   CHART;    NO  GAIN 

This  is  one  of  our  early  charts  showin?  an  entire  lark  of  progress 
dnrinj?  a  period  of  20  wool^s.  Whih'  this  boy  was  under  observa- 
tion, all  possible  causes  for  his  underweight  that  were  known  at 
that  time  were  removed.  Treatment  was  continued  for  2U  M'ceks 
more  with  no  relative  gain.  The  cause  was  overfatigue,  the  sig- 
nificance of  which  was  not  then  recognized.  Average  weight  for 
age  was  the  standard  in  use  at  that  time,  and  as  this  boy  belonged 
naturally  to  the  group  under  the  average  size,  it  was  practically 
Impossible  for  him  to  attain  the  average  weight 
for  his  age. 

pared  with  the  record  of  one  of  our  nutrition 
classes. 


^  See  footnote,  p.  191. 


288 


EXTENT  OF  MALNUTRITION 

Contrast  the  outcome  of  these  limited  pro- 
grams with  the  results  that  have  followed  a 
careful  use  of  the  procedure  outlined  in  this 
book.    Figure  42  show^s  what  may  be  expected 


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Figure  41.    jstutrition  class  and  diet  classes  compared 

This  chart  illustrates  the  g.iins  made  in  two  classes  conducted  with 

special   emphasis  on   dietary   standards,   compared  with    the   results 

accomplished   in   a   nutrition    class   under   similar   social   conditions, 

where  attention  was  siven  to  all  the  essentials 

of  health. 


in  a  nutrition  class  carried  on  under  ordinary 
circumstances  with  good  cooperation  of  the  par- 
ents. Figure  43  reveals  the  still  higher  results 
obtained  in  a  private  school  which  adds  to  the 
usual  good  conditions  the  potent  and  significant 
factor  of  a  sane  school  program  where  health  is 
considered  as  a  matter  of  fundamental  impor- 

289 


NUTRITION  AND  GROWTH  IN  CHILDREN 

tance,  essential  to  education  and  in  no  way  an- 
tagonistic to  it.  Figure  44  registers  results  re- 
cently secured  in  a  class  of  "contact"  cases 
(children  who  had  been  exposed  to  tubercu- 


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FiGUBE  42.  A  1918  CLASS  AT  THE  BERKELET  INFIRMAEY, 
BOSTON 

Half  a  dozen  nationalities  were  represented  in  this  group,  as  well 

as  a   wide   variety   of    family    circiimstanpes.      The   causes   of   their 

malnutrition  were  equally  varied,  but  all  came  up  to  normal  weight, 

making  more  than  five  times  the  average  rate  of  gain. 

(Mabel  Skilton,  nutrition  worker.) 

losis),  in  a  nutrition  camp  which  was  under 
full  control  of  the  nutrition  worker  24  hours 
a  day. 

Table  VIII  shows  what  has  been  accom- 
plished in  representative  classes  working  on  our 
nutrition  program.     This  plan  has  proved  ef- 

290 


EXTENT  OP  MALNUTRITION 

ficacious  in  removing  malnutrition  in  a  wide 
range  of  situations,  including  children  in  the 


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FlQUEE  43. 


CLASSES  IN  THE  FRANCIS  W.  PABKEB  SCHOOL, 
CHICAGO,  1920 


In  this  school  nntrition  work  has  the  hearty  cooperation  of  princi- 
pal and  teachers,  with  tlie  result  that  five  nutrition  classes,  con- 
taining 70  of  th{^  most  seriously  underweight  children,  made  an 
average  gain  of  550  per  cent  during  the  first  seven  weeks  of  class 
treatment.  (Elizabeth  McCormick  Memorial  Fund, 
Marion  Moseley,  nutrition  worker.) 


homes  of  wealthy  and  poor  alike,  in  public, 
parochial,  and  private  schools,  orphan  asylums, 

291 


NUTBITION  AND  GROWTH  IN  CHILDREN 


FiGimE  44. 


GROUP  GAIN   AT   A  NUTRITION   CAMP  IN  GBAND 
RAPIDS,    MICHIGAN,    1920-21 


This  chart  shows  a  remarkablo  jrain  of  1.400  per  cent  for  28  chil- 
dren of  school  age.  Our  nutrition  program  has  been  strictly  fol- 
lowed, with  special  reference  to  the  prevention  of  overfatigue, 
although  a  considerable  number  of  the  children  attended  school  all 
day.  The  camp  was  maintained  for  the  first  two  months  of  1021  at 
a  food  cost  of  35  cents  per  day  per  child,  and  the  total  cost  has  not 
exceeded  ?7.12  per  capita  per  week.  This  is  not  a  chronological 
chart,  but  a  composite  of  the  gains  of  the  actual  first,  second,  third, 
and  fourth  weeks,  etc.,  of  the  various  members  of  the  group,  show- 
ing the  more  rapid  rate  of  gain  during  the  early  weeks,  tapering 
off  as  the  children  approached  normal  weight.  (Tuberculosis 
Association,  Enid  Bailey,  nutrition  worker.) 


summer  camps,  hospital  out-patient  depart- 
ments, social  settlements,  and  in  child-helping 
organizations  of  all  kinds. 

292 


EXTENT  OF  MALNUTRITION 


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EXTENT  OP  MALNUTRITION. 


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297 


NUTRITION  AND  GROWTH  IN  CHILDREN 


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298 


EXTENT  OF  MALNUTRITION 


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3  A 


EXTENT  OF  MALNUTRITION 

Two  groups  listed  under  Boston  well  illus- 
trate the  difference  in  the  results  secured  when 
there  is  reasonable  cooperation  and  when  this 
cooperation  is  lacking.  These  are  the  Berkeley 
Infirmary  and  the  Tuberculosis  groups,  where 
the  classes  were  conducted  under  similar  con- 
ditions in  buildings  a  few  blocks  apart. 

The  children  in  the  Tuberculosis  classes  came 
largely  from  a  district  that  is  known  as  one  of 
the  most  congested  areas  in  the  world.  In  spite 
of  the  evident  need  to  safeguard  their  health 
in  every  possible  way,  whenever  the  demands 
of  health  and  school  appeared  to  conflict,  the 
school  authorities  decided  to  enforce  the  latter. 
They  objected  to  absence  on  account  of  dental 
work  or  adenoid  and  tonsil  operations,  and  were 
unwilling  to  modify  the  school  program  suf- 
ficiently to  allow  the  children  time  for  the  rest 
periods  which  they  required. 

The  Infirmary  class,  on  the  other  hand,  was 
made  up  of  children  who  came  from  outside 
districts  in  which  the  schools  were  ready  to  co- 
operate, with  the  result  that  where  the  one 
group  made  only  205  per  cent  of  the  expected 
rate  of  gain,  the  other  progressed  at  the  rate  of 
525  per  cent. 

The  remarkable  gains  appearing  in  groups 
under  institutional  management  are  explained 

300 


NUTRITION  AND  GROWTH  IN  CHILDREN 

by  the  regularity  of  their  daily  program  and 
freedom  from  the  interruptions,  excitement, 
and  nervous  stimulation  of  the  average  house- 
hold. When  the  importance  of  home  control  is 
fully  recognized,  these  results  can  be  achieved 
in  the  home,  where,  under  proper  organization, 
even  more  favorable  conditions  for  growth  and 
development  should  be  attainable. 

The  highest  individual  rates  of  gain  recorded 
were  found  to  be  closely  associated  with  a  previ- 
ous condition  of  serious  underweight. 

"While  these  boys  and  girls  have  been  getting 
well,  they  have  also  been  receiving  health  edu- 
cation which  tends  to  make  their  recovery 
permanent.  These  results  have  been  brought 
about  for  the  most  part  without  taking  children 
out  of  their  own  environment  or  making  ex- 
traordinary changes  in  their  daily  programs, 
and  without  adding  to  the  expense  for  food.  In 
cases  wherein  extra  milk  was  required,  it  has 
usually  been  possible  to  offset  this  by  a  saving 
in  some  other  item  of  the  household  budget. 

A  study  of  the  results  accomplished  in  scores 
of  classes  makes  it  clear  that  any  group  work- 
ing on  our  nutrition  program  should  make  a 
gain  of  at  least  200  per  cent  of  the  normal  ex- 
pectation. The  work  has  not  been  carried  on 
where  conditions  were  specially  favorable  for 

301 


EXTENT  OF  MALNUTRITION 

securing  high  rates  of  gain,  but,  on  the  con- 
trary, in  what  would  be  considered  the  most  un- 
favorable localities,  such  as  the  West  and  South 
Ends  of  Boston,  the  East  Side  of  New  York, 
and  the  stockyard  district  of  Chicago.  It  is 
therefore  a  demonstration  that  with  proper  care 
and  intelligent  planning  malnutrition  can  be 
eliminated  from  any  community. 


APPENDICES 


APPENDIX  I 

TABLES  OF  WEIGHTS 
Table  I. — A\'erage  Weights  of  Children  at  Vaeious  Heights 


BOYS 

GIRLS 

Average 

7 

10 

Average 

7 

10 

Height, 
Inches 

Weight 
for 

per  cent 
Under- 

per cent 
Under- 

Weight 
for 

per  cent 
Under- 

per cent 
Under- 

Height, 
inches 

Height, 

weight, 

weight, 

rielght. 

weight, 

weight. 

pounds 

pounds 

pounds 

pounds 

pounds 

pounds 

•21 

8.2 

7.6 

7.4 

7.9 

7.3 

7.1 

21* 

*22 

9.7 

9.0 

8.7 

9.4 

8.7 

8.5 

22* 

•23 

11.1 

10.3 

10.0 

11.0 

10.2 

9.9 

23^ 

•24 

12.5 

11.0 

11.3 

12.5 

11.6 

11.3 

24* 

•25 

i:j.9 

12.9 

12.5 

14.0 

13.0 

12.0 

25* 

•26 

15.3 

14.2 

13.8 

ir..5 

14.4 

14.0 

26  • 

•27 

10.9 

15.7 

15.2 

17.2 

16.0 

15.5 

27^ 

•28 

18.5 

17.2 

16.7 

18.S 

17.5 

16.9 

28* 

•29 

20.2 

18.8 

18.2 

20.5 

19.1 

18.5 

29* 

•,*S0 

21.7 

20.2 

19.0 

22.0 

20.5 

19.8 

30* 

•31 

23.2 

21.6 

20.9 

23.4 

21.8 

21.1 

31* 

•32 

24.5 

22.8 

22.1 

24.8 

23.1 

22.3 

32* 

•33 

25.9 

24.1 

23.3 

20.0 

24.2 

23.4 

33* 

•34 

27.3 

25.4 

24.6 

27.3 

25.4 

24.6 

34* 

•35 

28.7 

20.7 

25.8 

28.6 

20.6 

25.7 

35* 

•36 

30.0 

27.9 

27.0 

30.0 

27.9 

27.0 

36* 

•37 

31.6 

29.4 

28.4 

31.5 

29.3 

28.4 

37* 

•38 

3:5.2 

30.9 

29.9 

32.7 

30.4 

29.4 

38* 

39 

36.3 

33.8 

32.7 

35.7 

33.2 

32.1 

39 

40 

38.1 

35.4 

34.3 

37.4 

34.8 

33.7 

40 

41 

39.8 

37.0 

35.8 

39.2 

36.5 

35.3 

41 

42 

41.7 

38.8 

37.5 

41.2 

38.3 

37.1 

42 

43 

43.5 

40.5 

39.2 

43.1 

40.1 

38.8 

43 

44 

45.4 

42.2 

40.9 

44.8 

41.7 

40.3 

44 

45 

47.1 

43.8 

42.4 

40.3 

43.1 

41.7 

45 

46 

49.5 

46.0 

44.6 

48.5 

45.1 

43.7 

46 

47 

51.4 

47.S 

40.3 

50.9 

47.3 

45.8 

47 

48 

53.0 

49.3 

47.7 

53.3 

49.6 

48.0 

48 

49 

55.4 

51.5 

49.9 

55.8 

51.9 

50.2 

49 

50 

59.6 

55.4 

53.6 

58.3 

54.2 

52.5 

50 

51 

62.5 

58.1 

50.3 

61.1 

50.8 

55.0 

51 

52 

65.8 

61.1 

59.2 

63.8 

59.3 

57.4 

52 

53 

68.9 

64.1 

62.0 

06.8 

62.1 

00.1 

53 

54 

72.0 

07.0 

04.S 

70.3 

65.4 

63.3 

54 

55 

75.4 

70.1 

67.9 

74.5 

69.3 

07.1 

."i."> 

56 

79.2 

73.7 

71.3 

78.4 

72.9 

70.0 

56 

57 

82.8 

77.0 

74.5 

82.5 

70.7 

74.3 

57 

58 

87.0 

80.9 

78.3 

86.0 

80.5 

77.9 

58 

59 

91.1 

84.7 

82.0 

91.1 

84.7 

82.0 

59 

60 

95.2 

88.5 

85.7 

90.7 

89.9 

87.0 

60 

61 

99.3 

92.3 

89.4 

102.5 

95.3 

92.2 

61 

62 

103.8 

00.5 

93.4 

110.4 

102.7 

99.4 

62 

63 

108.0 

100.4 

97.2 

118.0 

109.7 

100.2 

63 

64 

114.7 

106.7 

103.2 

123.0 

114.4 

110.7 

64 

65 

121.8 

113.3 

109.6 

130.0 

120.9 

117.0 

65 

66 

127.8 

118.9 

115.0 

137.0 

127.4 

123.3 

66 

67 

132.6 

123.3 

119.3 

143.0 

133.0 

128.7 

67 

68 

138.9 

129.2 

125.0 

146.9 

136.0 

132.2 

68 

•  Without  clothing. 


305 


NUTRITION  AND  GROWTH  IN  CHILDREN 


Table  II. 


-Average  Weight  and  Height  Measubements  of  Boys 
AT  Various  Ages 


Age 

Age 

Height  in 
Inches 

Weight  In 
Pounds 

Height  in 
Inches 

Weight  In 

Pounds 

Years 

Months 

Years 

Months 

Birth 

0 

•20.6 

'     •   7.55 

9 

0 

50.0 

59.6 

2 

•22.5 

•10.4 

9 

2 

50.3 

60.6 

4 

•24.5 

•13.2 

9 

4 

50.6 

61.5 

6 

•26.5 

♦16.0 

9 

6 

51.0 

62.5 

8 

•27.5 

*17.7 

9 

8 

51.3 

63.5 

10 

•28.5 

•19.3 

9 

10 

51.6 

64.4 

0 

•29.5 

•21.0 

10 

0 

51.9 

65,4 

2 

•30.3 

•22.1 

10 

2 

52.2 

66.3 

4 

•31.1 

•23.3 

10 

4 

52.5 

67.2 

6 

•32.0 

•24.5 

10 

6 

52.7 

68.0 

8 

•32.7 

•25.5 

10 

8 

53.0 

68.9 

10 

•33.4 

•26.4 

10 

10 

53.3 

69.8 

2 

0 

•34.0 

•27.3 

11 

0 

53.6 

70.7 

2 

2 

•34.7 

•28.2 

11 

2 

53.9 

71.7 

2 

4 

•35.4 

•29.1 

11 

4 

54.2 

72.7 

2 

6 

•36.0 

•30.0 

11 

6 

54.5 

73.8 

2 

8 

•36.5 

•30.8 

11 

8 

54.8 

74.8 

2 

10 

•37.0 

•31.6 

11 

10 

55.1 

75.9 

3 

0 

•37.5 

•32.5 

12 

0 

55.4 

76.9 

3 

2 

•38.0 

•33.2 

12 

2 

55.8 

78.2 

3 

4 

•38.5 

•34.0 

12 

4 

56.1 

79.5 

3 

6 

•39.0 

•34.7 

12 

6 

56.5 

80.8 

3 

8 

•39.5 

•35.4 

12 

8 

56.8 

82.1 

3 

10 

•40.0 

•36.1 

12 

10 

57.2 

83.5 

4                0      1 

•40.5 

•36.8 

13 
13 

0 

57.5 
57.9 

84.8 

4 

0 

39.5 

37.2 

86.5 

4 

2 

89.9 

37.9 

13 

4 

58.3 

88.3 

4 

4 

40.2 

38.5 

13 

6 

58.7 

90.0 

4 

6 

40.6 

89.2 

13 

8 

59.2 

91.8 

4 

8 

41.0 

89.8 

13 

10 

59.6 

93.5 

4 

10 

41.4 

40.5 

14 

0 

60.0 

95.2 

5 

0 

41.7 

41.2 

14 

2 

60.5 

97.2 

5 

o 

42.1 

41.8 

14 

4 

61.0 

99.3 

5 

4 

42.4 

42.4 

14 

6 

61.5 

101.3 

5 

6 

42.8 

43.1 

14 

8 

61.9 

103.3 

5 

8 

43.2 

43.8 

14 

10 

62.4 

105.3 

5 

10 

43.5 

44.5 

15 

0 

62.9 

107.4 

6 

0 

43.9 

45.2 

15 

2 

63.2 

109.7 

6 

2 

44.3 

45.9 

15 

4 

63.6 

111.9 

6 

4 

44.7 

46.6 

15 

6 

63.9 

114.2 

6 

6 

45.1 

47.3 

15 

8 

64.2 

116.5 

6 

8 

45.4 

48.1 

15 

10 

64.6 

118.8 

6 

10 

45.7 

48.8 

16 

0 

64.9 

121.0 

7 

0 

46.0 

49.5 

16 

2 

65.1 

122.5 

7 

2 

46.5 

50.3 

16 

4 

65.5 

124.0 

7 

4 

46.9 

51.2 

16 

6 

65.7 

125.5 

7 

6 

47.4 

52.0 

16 

8 

65.9 

127.0 

7 

8 

47.9 

52.8 

16 

10 

66.1 

128.5 

7 

10 

48.3 

53.6 

17 

0 

66.5 

130.0 

8 

0 

48.8 

54.5 

17 

2 

66.7 

130.9 

8 

2 

49.0 

55.4 

17 

4 

66.8 

131.7 

8 

4 

49.2 

56.2 

17 

6 

67.0 

132.6 

8 

6 

49.4 

57.1 

17 

8 

67.2 

133.4 

8 

8 

49.6 

57.9 

17 

10 

67.3 

134.3 

8 

10 

49.8 

58.8 

18 

0 

67.4 

135.1 

•  without  clotbins 


306 


TABLES  OF  WEIGHTS 


Table  III. 


-AvEBAQE  Weight  and  Height  Measubements  of  Gibls 
AT  Vakiods  Ages 


Age 

Age 

Height  In 
Inches 

Weight  In 
Pounds 

Height  in 
Inches 

Weight  in 

Pounds 

Years 

Months 

Years 

Months 

Birth 

0 

•20.5 

•  7.16 

9 

0 

49.7 

57.4 

2 

•22.3 

•  9.9 

9 

2 

50.0 

58.3 

4 

•24.2 

•12.7 

9 

4 

50.4 

59.2 

6 

•26.0 

•15.5 

9 

6 

50.7 

60.2 

8 

•27.0 

•17.2 

9 

8 

51.0 

61.1 

10 

•28.0 

•18.8 

9 

10 

51.4 

62.0 

0 

•29.0 

•20.G 

10 

0 

51.7 

62.9 

2 

•29.8 

•21.7 

10 

2 

52.1 

64.0 

4 

•30.6 

•22.8 

10 

4 

52.4 

65.1 

6 

•31.4 

•24.0 

10 

6 

52.8 

66.2 

8 

•32.0 

•24.8 

10 

8 

53.2 

67.3 

10 

•32.7 

•25.6 

10 

10 

53.5 

68.4 

2 

0 

•33.4 

•26.5 

11 

0 

53.8 

69.5 

2 

2 

•34.0 

•27.3 

11 

2 

54.1 

71.0 

2 

4 

•34.6 

♦28.1 

11 

4 

54.5 

72.6 

2 

6 

•3r..3 

•29.0 

11 

6 

54.9 

74.1 

2 

8 

•35.9 

•29.8 

11 

8 

55.3 

75.7 

2 

10 

•36.5 

•30.6 

11 

10 

55.7 

77.2 

3 

0 

•37.0 

•31.5 

12 

0 

56.1 

78.7 

3 

2 

•37.5 

•32.1 

12 

2 

56.5 

80.4 

3 

4 

•38.0 

•32.7 

12 

4 

56.9 

82.0 

3 

6 

•38.5 

•33.3 

12 

6 

57.3 

83.7 

3 

8 

•39.0 

•34.0 

12 

8 

57.7 

85.4 

3 

10 

•39.5 

•34.6 

12 

10 

58.1 

87.0 

4 

0 

•40.0 

•35.3 

13 
13 

0 

2 

58.5 
58.9 

88.7 

4 

0 

39.3 

36.2 

90.3 

4 

2 

39.7 

36.8 

13 

4 

59.2 

91.9 

4 

4 

40.0 

37.4 

13 

6 

59.5 

93.5 

4 

6 

40.4 

38.0 

13 

8 

59.8 

95.1 

4 

8 

40.7 

38.6 

13 

10 

60.1 

96.7 

4 

10 

41.0 

39.2 

14 

0 

60.4 

98.3 

6 

0 

41.3 

39.8 

14 

2 

60.6 

99.7 

6 

2 

41.6 

40.4 

14 

4 

60.8 

101.1 

5 

4 

41.9 

41.0 

14 

6 

61.0 

102.5 

5 

6 

42.3 

41.6 

14 

8 

61.2 

103.9 

6 

8 

42.6 

42.2 

14 

10 

61.4 

105.3 

5 

10 

42.9 

42.8 

15 

0 

61.6 

106.7 

6 

0 

43.3 

43.4 

15 

2 

61.7 

107.6 

6 

2 

43.7 

44.1 

15 

4 

61.8 

108.6 

6 

4 

44.1 

44.8 

15 

6 

61.9 

109.5 

6 

6 

44.5 

45.5 

15 

8 

62.0 

110.4 

6 

8 

44.9 

46.2 

15 

10 

62.1 

111.3 

6 

10 

45.3 

46.9 

16 

0 

62.2 

112.3 

7 

0 

45.7 

47.7 

16 

2 

62.3 

112.8 

7 

2 

46.0 

48.5 

16 

4 

62.4 

113.3 

7 

4 

46.4 

49.3 

16 

6 

62.5 

113.8 

7 

6 

46.7 

50.1 

16 

8 

62.5 

114.4 

7 

8 

47.0 

50.9 

16 

10 

62.6 

114.9 

7 

10 

47.4 

51.7 

17 

0 

62.7 

115.4 

8 

0 

47.7 

52.5 

8 

2 

48.0 

53.3 

8 

4 

48.4 

54.1 

8 

6 

48.7 

55.0 

8 

8 

49.0 

55.8 

8 

10 

49.4 

56.6 

•  without  clothing. 


307 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Table  IV. — Table  Showing  Increases  in  Weight  at  Various 
Ages  by  Years,  Quarters,  and  Weeks 


BOYS 


Age 

Year — 52  Weeks 

Quarter — 
13  Weeks 

Week 

Pounds 

Ounces 

Pounds 

Ounces 

Pounds 

Ounces 

Birth  to    1  year 

1  to     2  years 

2  to    3  years 

3  to    4  years 

4  to     5  years 

5  to    6  years 

6  to     7  years 

7  to    8  years 

8  to    9  years 

9  to  10  years 

10  to  11  years 

11  to  12  years 

12  to  l.S  years 

13  to  14  years 

14  to  15  years 

15  to  16  years 

13.45 
6.3 
5.2 
4.3 
4.0 
4.0 
4.3 
5.0 
5.1 
5.8 
5.3 
6.2 
7.9 

10.4 

JO  o 

13.Q 

215.2 

100.8 

8.S.2 

68.8 

64.0 

64.0 

68.8 

80.0 

81.6 

92.8 

84.8 

99.2 

126.4 

166.4 

195.2 

217.6 

3.3625 

1.575 

1.3 

1.075 

1.0 

1.0 

1.075 

1.25 

1.275 

1.45 

1.325 

1.55 

1.975 

2.6 

3.05 

3.40 

53.8 
25.2 
20.8 
17.2 
16.0 
16.0 
17.2 
20.0 
20.4 
23.2 
21.2 
24.8 
31.0 
41.6 
48.8 
54.4 

.259 
.121 
.100 
.083 
.077 
.077 
.083 
.096 
.098 
.112 
.102 
.119 
.152 
.200 
.235 
.262 

4.14 
1.94 
1.60 
1.32 
1.23 
1.23 
1.32 
1.54 
1.57 
1.79 
1.63 
1.91 
2.43 
3.20 
3.75 
4.18 

GIRLS 


Age 

Year— 52  Weeks 

Quarter — 
13  Weeks 

Week 

Pounds 

Ounces 

Pounds 

Ounces 

Pounds 

Ounces 

Birth  to     1  year 

1  to    2  years 

2  to    3  years 

3  to    4  years 

4  to    5  years 

5  to    6  years 

6  to     7  years 

7  to    8  years 

8  to    9  years 

9  to  10  years 

10  to  11  years 

11  to  12  years 

12  to  13  years 

13  to  14  years 

14  to  15  years 

15  to  16  years 

13.34 
6.0 
5.0 
3.8 
3.6 
3.6 
4.3 
4.8 
4.9 
5.5 
6.6 
9.2 

10.0 
9.6 
8.4 
5.6 

213.44 

90.0 

80.0 

60.8 

57.6 

57.6 

68.8 

76.8 

78.4 

88.0 

10.^6 

147.2 

160.0 

1.53.6 

134.4 

89.6 

3.335 

1.50 

1.25 

.95 

.9 

.9 
1.075 
1.2 
1.225 
1.375 
1.65 
2.3 
2.5 
2.4 
2.1 
1.4 

53.36 

24.0 

20.0 

15.2 

14.4 

14.4 

17.2 

19.2 

19.6 

22.0 

26.4 

36.8 

40.0 

38.4 

33.6 

22.4 

257 
115 
096 
073 
069 
069 
083 
092 
094 
106 
127 
177 
192 
185 
175 
108 

4.11 
1.85 
1.54 
1.17 
1.11 
1.11 
1.32 
1.47 
1.51 
1.69 
2.03 
2.83 
3.08 
2.95 
2.59 
1.72 

308 


TABLES  OF  WEIGHTS 

The  tables  on  pages  305  and  308  are  based  upon 
those  on  pages  306  and  307.  The  material  of  the  lat- 
ter for  the  first  four  years  is  taken  from.  Holt's 
Diseases  of  Infancy  and  Childhood  (1920)  ;  that  for 
the  succeeding  years  is  derived  principally  from  the 
work  of  Boas,  Burk,  Bowditch,  and  Smedley.  The 
weights  and  heights  in  Holt's  table  are  without  cloth- 
ing, while  those  of  the  later  years  are  with  indoor 
clothing  but  without  shoes. 

It  will  be  noted  that  the  figures  for  the  later  years 
differ  from  the  Boas-Burk  tables  by  six  months.  Our 
reason  for  setting  the  figures  forward  half  a  year  is 
that  in  their  original  form  they  represent  averages 
that  include  the  very  large  number  of  children 
whom  our  clinical  experience  and  studies  of  entire 
school  groups  find  to  be  seriously  malnourished.  The 
tables  in  their  present  form  run  lower  at  the  various 
ages  than  those  made  in  studies  concerned  mainly 
with  normal  children.  As  they  are  here  printed  they 
afford  the  best  working  standard  for  use  until  such 
a  time  as  sufficient  data  are  secured  from  weighing 
and  measuring  a  large  number  of  children  who  are 
normal. 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Table  V. — Table  Showing  Weight  of  Children's  Clothinq 
AT  Vabious  Ages 


BOYS 


Age 

Indoor 

Clothing, 

Pounds 

Shoes, 
Pounds 

Outdoor 

Clothing. 

Pounds 

Total 
Pounds 

3 

6 

7-  9 
10-12 
13-15 

.75 
1.5 
2.0 
2.0 
2.5 

.25 
1.0 
1.25 
1.5 
1.9 

1.0 
1.0 
1.0 
1.5 
1.6 

2.0 

3.5 

4.25 

5.0 

6.0 

GIRLS 


Age 

Indoor 

Clothing, 

Pounds 

Shoes, 
Pounds 

Outdoor 

Clothing, 

Pounds 

Total 
Pounds 

3 
6 

7-  9 
10-12 
13-15 

.75 
1.25 
1.5 
1.75 
2.0 

.25 
1.0 
1.0 
1.0 
1.25 

1.0 

1.0 

1.25 

1.5 

1.75 

2.0 

3.25 

3.75 

4.25 

5.0 

These  figures  were  secured  by  weighing  children's 
outfits  in  a  number  of  representative  stores  and  check- 
ing the  results  by  the  weight  of  clothing  actually 
worn.  They  indicate  conditions  in  the  month  of  May, 
midway  between  the  extremes  of  winter  and  summer. 
Investigation  shows  that  the  difference  in  the  weight 
of  indoor  clothing  due  to  temperature  or  season 
seldom  amounts  to  more  than  three-quarters  of  a 
pound  at  these  ages. 

By  ''Indoor"  clothing  is  meant  the  clothing  usually 
worn  in  the  house  or  at  school,  excluding  coat  and 
shoes,  which  should  be  removed  before  weighing. 
"Outdoor"  clothing  includes  cap  or  hat  and  the  coat 
previously  referred  to.  The  "Total"  in  the  table 
is  the  sum  of  the  three  previous  columns,  thus  repre- 
senting the  child's  entire  outfit  when  he  is  out  of 
doors. 

310 


APPENDIX  II 

FORMS  FOR  NUTRITION  RECORDS 


Name 

Age    Yrs.     Mos. 

Address 

Birthday 

School 

Grade 

Teacher 

Parent 

Height 

Average  Height 

Weight 

Average   Weight 

Underweight — Normal- 

-Overweight                          % 

Date 

FOBM  I.      INDEX   KECOBD   CARD,    SIZE,  3  BY  5   INCHES 

This  form  is  used  for  the  first  record  at  the  time  of 
the  weighing  and  measuring,  before  the  nutrition 
class  is  formed.  The  cards  may  be  grouped  to  show 
the  number  of  children  of  average  weight,  the  border- 
line cases  less  than  seven  per  cent  underweight,  the 
malnourished  who  are  seven  per  cent  or  more  under- 
weight, and  the  overweight  who  are  twenty  per  cent 
or  more  overweight  for  height.  • 

A  system  of  classification  with  colored  cards  has 
been  worked  out  by  Dr.  Burger,  of  the  Physical  Edu- 
cation Department  of  the  Kansas  City  Schools,  where 

311 


NUTRITION  AND  GROWTH  IN  CHILDREN 


CARD  WHITE 
ALL  RIGHT 


Age ^ _.. Years _ Months.    Date  of  first  weighing....^ _...~_. 

Height „ ....inches.      Weight pounds 

Average  weight  for  height pounds 

Weigh  yourself  each  month  and  record  belowr 


192 

Date 

Lbs. 

September 

October 

_„. 



November 





December 

192 
January 

February 

March 

April 


Date 

Lbs. 

192 

May 

June 

July' 
August 


Date 


Lbs 


"ALL  RIGHT"  means 

that  you  are  up  to  the  average  weight  for  your  height. 

Try  to  come  up  to  your  "best  weight"  which  is  about ,p6unds  above 

the  average. 

At  your  age  you  should  gain  about..-. pounds  each  .month. 

If  you  fail  to  gain  properly  or  fall  below  the  average  find  the  cause  and 
remove  it. 

The  chief  causes  for  failure  to  gain  are: 

Diseased  adenoids  iand  tonsils;  lack  of  fresh  air;  over  fatigue:  late  hours; 
not  enough  food  of  the  right  kind;  fast  eating;  sweeU  between  meals;  the- 
use  of  tea  and  coffee. 

FOEM  n.      FRONT  AND  BACK  OF  WHITE  CLASSIFICATION  CAED. 
SIZE,  3  BY  4%   INCHES 

each  child  is  given  a  red,  white,  or  blue  card  accord- 
ing to  his  condition.    The  cards  bear  the  verse, 

Card  of  white,  all  right. 
Card  of  blue,  won't  do. 
Card  of  red,  danger  ahead. 
312 


FORMS  FOR  NUTRITION  RECORDS 


CARD  BLUE 
WON'T  DO 


Name , , - ..r„..,.....„ ....^ i 

AcldrcM _ — - .., 

Age Years. _ Months.    Date  of  first  weighing.^..., 

Height inches.       Weight pounds 

Average  weight  for  height - pounds. 

Weigh  yourself  each  month  and  record  below: 


192 

September 

October 

November 

December 


Date     Lbs 


192 
January 

February 

March 

April 


Date 

Lbs. 

192 
May 

June 

July 
August 


Date    Lbs. 


"WONT  DO"  means 

that  while  you  are  not  greatly  underweight  for  your  height  you  are  in  danger 
of  becoming  more  so  unless  you  discover  the  cause  amd  remove  it. 

At  your  age  you  should  gain  about pounds  each  month. 

Already  you  are pounds  underweight  for  your  height, 

TaJce  at  least  a  pint  of  milk  each  day  in  one  form  or  another. 

Gain  in  weight  and  change  your  blue  card  for  one  that  is  white. 

The  chief  causes  for  failure  to  gain  are: 

Diseased  adenoids  and  tonsils;  lack  of  fresh  air;  overfatigue:  late  hours; 
not  enough  food  of  the  right  kind;  fast  eating;  sweets  between  meals;  the 
use  of  tea  and  coffee. 

FOBM    III.      FKONT   AND    BACK    OF   BLUE    CLASSIFICATION    CARD, 
SIZE,  3  BY  4 Mi   INCHES 

We  have  made  use  of  this  system  of  classification, 
adding  a  fourth  color  to  the  series,  *  *  Card  slate,  over- 
weight," with  a  statement  on  the  reverse  of  each  card 
giving  instructions  how  to  correct  the  abnormal  con- 

313 


NUTRITION  AND  GROWTH  IN  CHILDREN 


CARD  RED 
DANGER  AHEAD 


Name. >._>._-„.... 

Address  ..^„.^^.>...» ^ - - "... 

Age _.....„..„Year8 .Months.     Date  of  first  weighing 

Height „ „ inches.       Weight_ pounds 

Average  weight  for  height „ _ •. pounds 


Weigh  yourself  eachjnonth  and  record  below: 

192 
September 

October 

Dale 

Lbs. 

192 
January 

February 

March 

April 

Date 

Lbs. 

192 
May 

June 

July 
August 

Date 

Lbs. 

November 

December 

"DANGER  AHEAD**  means 

(I.)    Less  endurance  in  games,  sports  emd  work. 

(2.)    Less  resistance  to  sickness. 

(3.)     Probably  always  remaining  underweight  and  underhelght- — stunted. 

At  your  age  you  ought  to  gain: pounds  each  month. 

You  are  already pounds  underweight  for  your  height.    Find  the  cause 

and  remove  it!  Gain  in  weight,  change  your  red  card  for  one  that  is 
blue..  Then  get  one  that  is  white  as  soon  as  you  can. 

The  chief  causes  for  failure  to  geun  are: 

Diseased  adenoids  and  tonsils;  lack  of  fresh  air;  ovcr.fatigue;  late  hours; 
not  enough  food  of  the  right  kind;  fast  eating:  sweets  between  meals;  the 
use  of  tea  and  coffee. 

Things  you  can  do : 

Take  a  quart  of  milk  a  day  in  one  form  or  another. 

Take  rest  periods  of  at  least  half  am  hour  before  mid-day  and  evening  meeJs. 
Take  mid-morning  and  mid-afternoon  lunches  without  sweets,  not  enough, 
lunch  to  spoil  appetite  for  the  next  meal. 


FORM   IV. 


FRONT   AND  BACK   OF  BED  CLASSIFICATION  CABD. 
SIZE,  3  BY  iVi  INCHES 


ditioD.  These  colored  cards  arouse  the  interest  of 
the  children  and  stimulate  all  to  work  for  white  cards, 
the  sign  of  normal  condition. 

314 


FORMS  FOR  NUTRITION  RECORDS 


CARD  SLATE 
OVERWEIGHT 


Naine....„^ ~ - « ~.~~.-~~~..— 

AddreM _ - ^..,...~ —^ — — 

Age Years Months.     Date  of  first  weighing „..„ 

Height inches.       Weight. „ „., pounds 

Average  weight  for  height _ _.. ™ _„«, — pounds 

Weigh  yourself  each  ndonth  and  record  below: 


192 

September 

October 

November 

L^ecember 


Date 

Lbs. 

192 
January 

February 

March 

April 


Date 


Lbs. 


192 

May 

June 

July 
August 


Date    Lbs. 


"OVERWEIGHT"  means 

less  endurance  and  efficiency  in   both  play-  and  work  as  well  as  lessened 
attractiveness  in  appearance. 

You  should  reduce  your  weight pounds  ftnd  get  a  white  card.    It  would 

be  better  to  lose  a  few  more  pounds. 

Begin  at  once  to  reduce  your  weight  to  the  nonnaL 

Take  less  of  high  value  foods  such  05  candy. .  p&stry,  cream  and  butter;  also 
avoid  eating  between  meals. 

Eat  fruit  and  vegetables. 

Do  not  reduce  more  than  a  pound  a  week. 

Work  for  a  White  Card! 


fobm:  v.    front  and  back  of  slate  classification  card, 
size,  3  by  41/^  inches 

A  buff  card  has  also  been  adopted,  Form  VI,  to 
hold  the  child's  complete  weight  record,  with  the 
dates  on  which  he  receives  the  various  colored  cards. 

315 


NUTRITION  AND  GROWTH  IN  CHILDREN 


NUTRITION  RECORD  CARD 


Name.—. 


Address — 

Date  ol  firjt  weigl^mg 


._ , -._■ Age Year* ^Months 

_ Birth  date „ 

-^.„__    Weight pounds.     Height inches. 


Average  weight  for  I 
Register  below  resul 

ht 

.      Per  cent  <"'«"'««.'''••' 

underweight.., 

ts  of  successive  weighings: 

192 

September 
October 
November 
December 

Date 

Lb*. 

192 

Date 

Lbs. 

192 
May 
June 
July 
August 

Date 

Lbs. 

February 

March 

April 







Dates  pupil  received  various  colored  cards; -... 

FILE  Tins  CARD   IN  OFFICF.  AND    PILL   IN   RECORDS   REQUIRED 
USE  RF.VER.SE  SIDE  FOR  NOTES 


FOEM  VI.    NUTBITION  EECOED  CABD  (BUFF),  SIZE,  3  BY  5  INCHES 

When  filed  according  to  the  color  classification,  these 
buff  cards  will  then  show  constantly  the  proportion 
of  overweight,  underweight,  borderline,  and  normal 
children  in  any  group. 


FORMS  FOR  NUTRITION  RECORDS 


MAUB                                                                          Huti<tl<«Cta>                                     Sdxasl                       Qvit 

ADDRESS  and  TaKphou  Nimlar                                                               D.u  ol  Si/n                              UsdtrMikt               Ite            % 

Datr 

' 

1 

' 

< 

' 

« 

' 

• 

' 

.0 

" 

" 

•> 

'» 

.< 

" 

'• 

l> 

» 

>l 

JJ 

" 

24 

If 

M 

R«t»#r.ej. 

'■""'£««,<,. 

Ui^ 

Cal<»)ca 

_ 

_ 

L 

u 

, ,., 



, 



^ 

■__ 

_ 

_ 

_ 

, ^ 

NMn« 

Aj»               yr»          moa. 

Height           is*.     Weight          Ha. 

Gained                      ol  in            wk>. 

Aetna] 

Gained                     ina.    in             wka. 

Average 

Expected  weekly  gab                   <au 

Eumliied  by  Dr. 

Dal* 

%  actual  of  expected  gain 

SUMMARY   OF  DEFECTS  FOUND 

DEFECTS  CORRECTED                  Date* 

2                                         7 

}                            a 

4                                           9 

J                                           10 

Pmiotu  A.  and  T.  Opentianii  Data* 

FREE  TO  CAIN.    Ye»   .    Date 

Na 

Uncertain 

HOME    COOPERATION      Good 

Fair 

Poor 

SCHOOL    PROGRAM 

Full  tme  double  .eHuin           hr» 

Full  time  iiogle  leaaion             hra. 

How  modified 

LUNCHES  (it.rt)                             REST 

PERIODS  (Kan) 

Mid.moming              wlu. 

ka. 

Mid..(terT.oon           wlc 

ka. 

FOOD   HABITS       Takej  milk           pta 

daJy 

t                                           "       cereal  daUy 

orraaiflnaHy 

HEALTH  HABITS      Bed  tune 

Riae« 

CHILD 

PAREMT  OR  REPRSSENTATIVB                        PHYSItfUN                      1 

Attended^        wlu.  out  of           wlu. 

wk.    out  of 

wka.                         wk*.  out  o«              wU 

FOBM   VII. 


FRONT   AND   BACK    OF   INDIVIDUAL   WEIGHT   CHART. 
SIZE,   4   15Y    6   INCHES 


The  record  on  the  face  of  this  individual  weight  chart 
is  copied  from  the  large  weight  chart  used  in  the  nutrition 
class.  The  summary  on  the  back  is  made  at  the  end  of 
the  quarter  or  half  year.  This  form  can  also  be  used  for 
recording  the  average  weekly  gains  of  a  class  or  group, 
being  rendered  more  effective  by  a  red  line  showing  the 
average  expected  gain  of  the  members  of  the  group. 

317 


*»     "J 


3f     S 


I       J 


3 


ft 

N 

1 

■ 

Si 

_ 

00 

l> 

vC 

l« 

,     ., 

n 

^ 

. 

o 

0^ 

XI 

I-. 

lO 

— • 

i 

s 

« 

s 

-s- 

0! 

^ 

X 

-1 

3 
.J 

^ 

/ 

s 

/ 

■ 

, 

) 

-tl- 

•c 
g 

.1 

111 

^-^  3 
\&6 


6   E 

5  I 


318 


FOEMS  FOR  NUTRITION  RECORDS 


Directions  for  Making  Out  the  Weight  Chart 

The  Actual  Weight  Line.  On  the  lower  line  of  the 
square  above  the  word  "Calories"  write  the  number 
of  pounds  that  the  child  weighs.  On  each  of  the  lines 
above  this  increase  the  figure  by  one.  Fill  in  the  dates 
of  the  weekly  weighings  on  the  top  horizontal  line. 
In  the  column  under  the  date  of  the  first  weighing 
place  a  dot  in  the  square  opposite  the  figure  indicat- 
ing the  child 's  weight — even  pounds  on  the  lower  line, 
half  pounds  on  the  middle  line,  and  quarters  in  the 
spaces  between.  Disregard  all  fractions  less  than  one- 
quarter  of  a  pound.  Continue  to  record  the  weekly 
weighings  in  the  same  way.  Connect  each  new  dot 
by  a  straight  line  with  the  dot  recording  the  previous 
weighing  and  thus  construct  the  child's  actual  weight 
line. 

The  Average  Weight  Line.  From  the  table  of 
weights  at  various  heights  (page  305)  find  the  average 
weight  for  the  child's  height,  and  indicate  by  a  dot 
opposite  that  figure  on  the  middle  vertical  line  in  the 
column  under  the  first  weighing  date.  From  the  table 
showing  increases  in  weight  (page  308)  determine  the 
expected  gain  for  13  weeks  according  to  the  age  of 
the  child,  and  indicate  by  a  dot  on  the  middle  ver- 
tical line  of  the  proper  square  in  the  column  under 
the  thirteenth  weighing  date.  Connect  these  two  dots 
by  a  straight  line  extending  across  the  remainder  of 
the  chart  at  the  same  angle.  This  is  the  average 
weight  line. 

When  the  actual  weight  line  reaches  the  average 
weight  line,  the  child  should  be  measured  again,  and 

319 


NUTRITION  AND  GROWTH  IN  CHILDREN 

if  he  has  grown  in  height  during  the  interval,  a  new 
average  weight  line  based  on  his  new  height  should  be 
computed.  He  should  be  graduated  only  when  he  has 
attained  the  weight  required  by  his  new  height. 


ON 

N 
nditior 


under  e 

j 

re.  Ere( 

lODS    DC 


^nr. 


Den — 1« 


>ure 

.•ccen 

»ry  lio' 

lary  lii 

■caput 

but 

nie 


Preae 
tbseot 


5  I-  i 


a    -s 


w     c: 


&     & 


cs    at 


a    -M 


a 

o 
"S 

T3 
■o 

B 

a 
Q 
o 

;2 
5 

c 

c 
'5 
O 

c  = 

as 

FORM    FOR    HISTORY    AND    PHYSICAL 


EXAMINATION  nutrition  clinics  for  delicate  children 

PHYSICAL   EXAMINATION 


1 

1  OHM (no 

N-  r.L-G\iiDiMr, 

Mr» 

r.tns 

OF 

UMILV 

IN^F'F.CTION     Biiglil— dull-  nefiouj— pMcgmatic— apailit'K 

SUMMARY  OF  DEFECTS    FOUND 

llcnllh 

Dill-  I! 

l,.Ca» 

dc'il^' 

GI.M:1:VL    rOVDinON     (;ooH-ra„-    pon,                               t,,™.  u.Je,  »e. 

UNDcnwi:iouT  Eon  lleiaQT       Pocmim       PfjicrNT 

Moutb  br«stber 

MUSCLES    Rraps  6rm-0,bby                                               PosWre.  Erecl-I.liguc 

Otbeb  Oetects 

N«m1  voice 

Moll», 

HEAD    Nuraial                Dassei  ptooj.neal                               Pedicgli 

Signs  ot' 

Granular  plaryiui 

Cl.ild.rn 

EVES    Pupils  equal— uoeqiinl         React  to  ligUl—dislooce         Molioos   notmal— abnormBl 

Naso-pLaryogcBl 

Cryplic  tooiils 

Vision     Right   /aO                     Lcit   /«0                 ISnellcD't  test) 

ObtlTuctioa 

KnLrged  «l.- 

NARES    Clear — cfusted— mucous  iliicliaigc — spur — deviftteil  septum 

ccrvical  gUads 

, 

MOUTU    Norruol— «p«o        Coug)>        Herpes        Mu^ui  mcmbmne.  Noriskl-p«Ie 

Eardruou  dull 

, 

TONGUE    Notaial-tnoiat-dry-bro.aisbeoal 

^ 


jNFOHMATIQM    RKGARDING   DinTH    AND   I.NFANCY 


ervic*] — cpiUocUeu 


RECOMMENDATIONS 


TEKTH    Good— Nui 


EABS    Right  drum:  Normd— dull' 


LftI  drum:     Normal— dull — retracted— bulging  CeriuneD — left 


PREVIOUS  DISKASES  IWITH  DATES) 


1.  left  mid-^leraal  lioe 


right  uid-sterDal  line 


"EICXHIRED  "BY- 


WECORDED  bY^ 


Apci  4lh— Jth— 6lh- 


d-clavicuUr  lioe 


FURTHER  EXAMINATION  I 


XR&y  of  Chest,  Dig 


Special  Nom,  Throat  aud  Sio 


louoda  Clear— impuc 


ci&lly  Red  Cells  ood  Hcmoglabla 


Repeated  attacks  iudig 

D  sritlioul  a 

parent  c 

Ilia 

Yes-No 

LUNGS;  Reiouaooc  good  I 

Habiu  as  to       Tea 

CoBe 

lrc«a 

e, 

ABDOMENi  Noroal-larg 

C.nd,o,..„lab 

«.. 

omeaU 

Wa.bi 

igdosrnfood 

LIVER    Dullaus        apaee- 

ighout        Reapiratioo  good  throughout  D'Espme 

distended — tympaoi  lie — tender —  hernia 
space— rib  to  coiul  border  mid -clavicular  line 


ADDITIONAL  NOTES  ON   PHYSICAL  EXAMINATION 


Does  chUd  take  cereals? 


SPLEEN;  Felt- 


GENITALS:  Normal  Prepuce    Long- 

EXTREMITIES;  K  J  -  Preseol  aod  equal- 


SKIN.  Smooth-rough— clear— sea 


Edema:  Preaeat- 


Murm 

urs:  None 

id  pulm.  accanluated 

(V>.isctman  ReacUno 

GENERAL   HEALTH   AND  HABITS 

soft  aystolic 

ape. 

ant.  aailUry  lioe 

Tampe/ature  Chart  Record 

General  Heoll  b :    Good  — hir — poor 

Frc 

ueol  colds: 

Yea- No 

loud  systolic  al 

putaoaic     ir.to 

mid.  .Hilary  line 

Skm  Testa  for  Proteins 

How  long  underweight 

Date  wh 

n  well  an.l  ilroog 

diastolic 

aortic 

angle  ol  acapnia 

Stoola  for  Parasites,  etc 

PRESENT  SYMPTOMS 


SPINE    Normal— rigid— cur VI 
CHEST:  Normal- barrel— Bat 


FEET:  Archea:  Good— Sal 


TEMPERATURE: 


NATION    FORM. 


SPECIAL    DIRECTIONS    FOR 


CHAPTER   IV. 


r) 


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321 


NUTRITION  CLINICS   FOR  DELICATE  CHILDREN 
Repobt  of  Nutrition  Class 

Name  of  Class   

Date — from  to  1921 

Reporter 

(A  report  is  due  every  two  weeks) 


Members  enrolled 

Members   present    

Number  gaining 

Ounces  gained 

Number  unchanged  or  losing 

Ounces   lost    

Average  gain    

Physician  present :    Yes — No    

Number  parents  present   

Number  diet  records  brought   

Number   red   stars    

Number   blue   stars    

Number  waiting  physical  examination. 
Number  requiring  A  and  T  operation . . 


Week  I 


Visitors 
Notes    . 


Week  II 


(Over) 


FOBM  XI.     FOBTNIGHTLY  REPORT  OF  NUTRITION   CLASS. 
SIZE,  414  BY  9%   INCHES 

322 


FORMS  FOR  NUTRITION  RECORDS 

The  form  shown  opposite  is  useful  in  cheeking  up 
a  class  to  see  that  the  essentials  of  the  nutrition  pro- 
gram are  being  carried  out.  It  shows  whether  the 
children  are  following  directions,  and  the  status  of 
the  group  with  respect  to  physical  examinations, 
necessary  operations,  and  gains  made.  The  reverse 
of  tiie  blank  is  shown  below. 


DIRECTIONS 

Date  first  fortnightly  report  from  the  day  of  the  first 
weighing  to  that  of  tl»e  tliird  weighing.  Week  I  closes  with 
second  weighing  and  Week  II  with  third. 

Count  for  first  enrollment  all  present  at  second  weighing 
whom  you  have  decided  to  admit  to  the  class. 

Remove  from  the  official  roll  names  of  all  children  absent 
for  two  consecutive  weeks.  (This  docs  not  mean  that  the 
nutrition  worker  is  to  discontinue  visits  or  in  any  way  lose 
connection  with  the  family.)  ReenroU  them  when  they  return 
to  class. 

In  determining  ounces  gained  or  lost  by  children  who  have 
been  absent  divide  the  gain  or  loss  since  the  last  weighing  by 
the  number  of  weeks  and  enter  the  result  in  the  proper  column. 

In  determining  average  gain  for  the  week,  subtract  ounces 
lost  from  ounces  gained  and  divide  the  remainder  by  the  num- 
ber  present. 


NUTRITION  AND  GROWTH  IN  CHILDREN 


NUTRITION  CLINICS  FOR  DEUCATE  CHILDREN.  IneoipoialeJ 

44  DVICHT  STREET.  BOSTON 


QUARTERLY  REPORT  TO  GENERAL  SECRETARY 


Nouoldui 

Report  (or  13  vedu  froin 

IM 

U 

in 

Ad<lro> 

ScW 

CnJo 

NuUitien  worVtf 

PSradon 

PrincipJ 

RESULTS  OF  WEIGHING  AND  MEASURING  CROUP  reOM  WHICH  CLASS  WAS  FORMED 


80  » 

CIUS 

ton  ssxu 

duUnn  votbcil  uj  Kuuni 

No 

10054 

No.. I007o 

No. lOtft 

Noraul  waiht    (tv<n«c  to  Xl% 
over  bcluuve) 

No. 

% 

No. % 

No % 

Bor  JerGM  (Uu  t>L<]>  7%  UDdor) 

No. . 

—% 

N» ,„» 

No % 

U<l<r«««hl  (77.  wxl  Bot.) 

Mo. 

% 

No. % 

N» % 

Ovcfwttght  (mort  tkoii  20%) 

No. . 

—7, 

No. % 

N«„__    % 

Avtwgt  iimbW  of  phywcol  J^ecta  (diviJc  tflUl  fitfpher  ol  defect*  by  wimbtr  of  com  eiominoj) 

fliycrim  prcient  out  of  13  me«tinn-  Total  nuipber  viate  mode  by  ptftatt 

ETpliration  of  oil  caiet  dropped 


MoUo:    C^cdcniaut  aitMBofay  «f  ^W9.  ■conooiie  coo^tioo  (wbethtf  woQ-to-do  or  poor,  etc) 

fobm:  xn.    front  page  of  quaktebly  bepoet  of  nutbition 

CLASS.      SIZE  of  blank  FOLDED,   81/^   BY   11   INCHES 

This  report  furnishes  a  class  summary  in  such 
form  that  the  results  may  be  compared  with  similar 
data  from  other  groups.  The  second  page  of  the 
blank   is    shown    opposite. 


324 


paixirj  JO 
I»r«v  1U33  i.j 


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p9f>09»V 


en 


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o 

O 
b 

H 

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o 
I-] 

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Ei) 
O 
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O 


325 


APPENDIX  III 

GLOSSARY 

Acne.  An  inflammatory  disease  of  the  sebaceous 
glands,  occurring  mostly  about  the  face,  chest,  and 
back. 

Adenoid.  A  mass  of  tissue  situated  at  the  posterior 
wall  of  the  upper  end  of  the  pharynx;  known  as 
the  pharyngeal  tonsil. 

Adherent  prepuce.  Abnormal  tightness  of  the  fore- 
skin. 

Alveolar  abscess.  A  collection  of  pus  in  a  tooth 
socket  or  cavity. 

Anaphylaxis.  Increased  susceptibility  to  the  action 
of  a  foreign  proteid  introduced  into  the  body,  in- 
duced by  a  first  injection  of  the  same  substance. 

Anemia.  A  condition  in  which  the  blood  is  reduced 
in  amount  or  is  deficient  in  red  blood  cells. 

Antineuritic.  Effective,  in  the  treatment  and  preven- 
tion of  neuritis. 

Antirachitic.  Effective  in  the  treatment  and  preven- 
tion of  rickets. 

Antiscorhutic.  Effective  in  the  treatment  and  preven- 
tion of  scurvy. 

Antrum.  A  nearly  closed  cavity  in  the  superior 
maxillary  bone,  communicating  with  the  middle 
passages  of  the  nose. 

Calory.  The  heat  unit  employed  in  the  study  of 
metabolism  J  the  amount  of  heat  required  to  raise 
326 


GLOSSARY 

the  temperature  of  one  kilogram  of  water  one  de- 
gree centigrade. 

Carhohydrate.  A  substance  containing  carbon,  hy- 
drogen, and  oxygen,  the  two  latter  in  the  propor- 
tion to  form  water.  The  sugars,  starches,  and  cel- 
lulose belong  to  the  class  of  carbohydrates. 

Cardiac.  1.  Relating  to  the  heart,  2.  Relating  to  the 
esophageal  orifice  of  the  stomach. 

Cardiospasm.  Spasmodic  contraction  of  the  cardiac 
end  of  the  stomach  or  of  the  adjoining  portion  of 
the  esophagus. 

Carious.    Decayed  or  decaying. 

Cerumen.  Ear  wax;  the  soft,  brownish  yellow  secre- 
tion of  the  glands  of  the  external  auditory  canal. 

Cervical.    Relating  to  the  neck. 

Chorea.  St.  Vitus'  dance;  a  nervous  disorder,  usually 
occurring  in  childhood,  characterized  by  irregular, 
spasmodic,  involuntary  movements  of  the  limbs  or 
facial  muscles. 

Duodenum.  The  first  division  of  the  small  intestine, 
in  adults  about  11  inches  or  12  fingerbreadths 
(hence  the  name)  in  length. 

Eczema.  An  inflammation  of  the  skin  often  accom- 
panied by  itching  or  burning. 

Emphysema.  A  swelling  due  to  the  presence  of  air 
in  the  interstices  of  the  connective  tissue  of  a  part. 

Endocarditis.  Inflammation  of  the  endocardium,  or 
lining  membrane  of  the  heart. 

Endocrine  glands.  Glands  which  furnish  an  internal 
secretion  to  the  body. 

Enuresis.    Involuntary  passage  of  urine. 

Eosinophilia.  An  increase  beyond  the  normal  in  the 
number  of  blood  cells  that  stain  readily  with  eosin. 

327 


NUTKITION  AND  GROWTH  IN  CHILDREN 

EsophagiLS.  The  gullet ;  a  museulo-membranous  canal 
extending  from  the  pharynx  to  the  stomach. 

Exacerhations.  The  periodical  aggravation  of  the 
febrile  condition  in  remittent  and  continued  fevers. 

Focal  infection.  An  infection  confined  ordinarily  to 
a  distinct  location,  such  as  the  tonsils  or  tooth 
sockets,  from  which  at  times  microorganisms  or  their 
toxins  escape  to  infect  other  regions  or  the  general 
system. 

Fulminating  appendicitis.  Appendicitis  marked  by  a 
sudden  onset  with  rapid  and  fatal  development. 

Gastritis.    Inflammation  of  the  stomach. 

Gingivitis.    Inflammation  of  the  gums. 

nypertrophic.  Marked  by  overgrowth  or  general  in- 
crease in  bulk  of  a  part  or  organ. 

Infantilism.  Retardation  of  mental  and  physical  de- 
velopment; the  persistence  into  later  years  of  the 
characteristics  of  childhood. 

Intraspinal.    Within  the  spinal  canal  or  spinal  cord. 

Intravenous.    Within  a  vein  or  veins. 

Leucocyte.  A  colorless  cell-mass,  such  as  a  white 
blood  corpuscle,  or  one  of  the  irregular  cells  found 
in  the  blood,  the  lymph,  in  pus,  or  as  wandering 
connective  cells  in  the  tissues  of  the  body. 

Malocclusion.  Abnormal  closing  of  the  teeth;  a  mis- 
fit of  the  masticatory  surfaces. 

Mastoiditis.  Inflammation  of  the  bony  structure  of 
the  temple  situated  below  and  behind  the  orifice 
of  the  ear. 

Naso-pharyngeal.  Pertaining  to  that  part  of  the 
pharynx  above  and  behind  the  soft  palate,  directly 
continuous  wdth  the  nasal  passages. 

Nephritis.    Inflammation  of  the  kidneys. 

328 


GLOSSARY 

Otitis.    Inflammation  of  the  ear. 

Otoscope.    An  instrument  for  examining  the  ear. 

Pediculosis.     Lousiness;  a  skin  disease  produced  by 

lice. 
Peritonitis.    Inflammation  of  the  peritoneum  or  sac 

lining  of  the  abdominal  cavity. 
Pharyngitis.    Inflammation  of  the  mucous  membrane 

and  underlying  parts  of  the  throat. 
Phlyctenular  keratitis.     Inflammation  of  the  cornea, 

or  outer  coat  of  the  eyeball,  accompanied  by  the 

formation  of  pustules  or  blisters. 
Proteid.    One  of  a  group  of  substances  constituting 

the  greater  part  of  the  animal  and  vegetable  tis- 
sues, all  containing  carbon,  hydrogen,  nitrogen,  and 

oxygen,    and   some    containing    in    addition    iron, 

phosphorus,  or  sulphur. 
Ptosis.    A  falling  or  sinking  down  of  any  organ. 
Pyelitis.    Inflammation  of  the  pelvis  of  the  kidney. 
Pyloric  stenosis.   A  narrowing  of  the  aperture  between 

the  stomach  and  the  small  intestine  (duodenum). 
Radiograph.     The  record  made  on  a  photographic 

plate  by  the  Roentgen  rays  or  rays  proceeding  from 

radium  or  other  radioactive  bodies. 
Bickets.    A  disease  occurring  in  infants  and  young 

children,  characterized  by  softening  of  the  bones. 
Sinus.     A  hollow  cavity  or  channel  in  the  cranial 

bones  communicating  with  the  nose. 
Syphilis,  hereditary.     An  infectious  venereal  disease 

existing  in  a  child  at  birth. 
Thyroid.     A  ductless  gland  lying  in  front  of  the 

trachea  which  furnishes  an  internal  secretion  of 

influence  upon  metabolism  and  important  in  the 

economy  of  the  body. 

329 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Tonsil.  A  small  mass  of  tissue  situated  on  either  side 
of  the  passage  between  the  mouth  and  the  pharynx. 

Toxemia.  Blood  poisoning  caused  by  the  poisonous 
products  of  the  body  cells  or  the  influence  of  micro- 
organisms. 

Trachea.  The  principal  air  passage  of  the  body;  the 
windpipe  extending  from  the  laiynx  to  the  bron- 
chial tubes,  connecting  through  these  with  the  lungs. 

Vaginitis,  gonorrheal.  Inflammation  of  the  vagina  or 
genital  canal  in  the  female,  due  to  a  specific  infec- 
tion of  the  mucous  membrane. 

Visceroptosis.  Abdominal  ptosis;  an  abnormal  sink- 
ing down  of  the  abdominal  organs. 

Description  of  Tests 

Cutaneous  proteid  test.  The  application  to  the  skin 
of  the  extract  of  various  proteids  to  determine  the 
reaction  of  the  individual,  which  is  indicated  by  a 
skin  eruption. 

Boentgeji-ray  test.  A  shadow  picture  made  by  plac- 
ing the  part  to  be  examined  between  the  Roentgen 
rays  and  a  sensitized  film  or  plate.  The  rays  pene- 
trate many  substances,  as  the  flesh,  that  are  im- 
pervious to  ordinary  light  rays,  but  bone  and  other 
substances  which  are  impervious  to  the  Roentgen 
rays  cast  a  shadow  on  the  plate  and  form  a  picture. 

von  Firquet  test.  The  inoculation  with  tuberculosis 
toxin,  which  causes  more  marked  inflammatory  re- 
action on  the  skin  of  tuberculosis  subjects  than  of 
normal  persons. 

Wassermann   test.     A   diagnostic   test   for   syphilis, 
based  upon  the  theory  of  complement  fixation,  car- 
ried out  upon  blood  samples. 
330 


APPENDIX  IV 

list  of  publications  of  nutrition  clinics  fob 

delicate  children,  incorporated,  44:  dwight 

street,  boston 

Forms 

NO. 

I.  Index  record  card,  3  by  5  inches. 

II.  White  classification  card,  3  by  4^/2  inches. 

III.  Blue  classification  card,  3  by  41/2  inches. 

IV.  Red  classification  card,  3  by  4V2  inches. 
V.  Slate  classification  card,  3  by  4^/2  inches. 

VT.   Nutrition  record  card  (buff),  3  by  5  inches. 
VII.    Individual  weight  chart,  4  by  6  inches. 
VIII.  "Weight  chart  for  use  in  nutrition  classes,    18  by  24 
inches. 
IX.   History  and  physical  examination  form,  14^^  by  8 
inches. 
X.    Registration  and  visible  record  form,  19  by  24  inches. 
XL   Fortnightly  report  of  nutrition  class,  4^  by  9^2 

inches 
XII.    Quarterly  report  of  nutrition  class,  8^2  by  11  inches, 
folded. 

XIII.  Tables  of  weight  in  relation  to  height  and  age,  4^ 

by  6  inches,  folded. 

XIV,  Nutrition  class  diploma,  5%  by  7%  inches. 

331 


NUTRITION  AND  GROWTH  IN  CHILDREN 

Pamphlets 

1.  "A  Nutrition  Clinic  in  a  Public  School,"  by  William 

R,  P.  Emerson,  M.D. 

2.  "Nutrition  Clinics  and  Classes:  Their  Organization  and 

Conduct,"  by  William  R.  P.  Emerson,  M.D. 

3.  Record  Book  for  Measured  Feeding,  by  William  R.  P. 

Emerson,  M.D. 
7.* "Defective  Nutrition  and  Growth:    A  Selected  Bibli- 
ography," by  Frank  A.  Manny. 
8.   "Physical  Defects  in  Children :  Report  of  Six  Hundred 
and  Two  Cases,"  by  William  R.  P.  Emerson,  M.D, 

14.  "Practical  Mental  Examinations  for  Growing  Chil- 
dren," by  A.  Warren  Stearns,  M.D. 

17.  "Malnutrition  in  Children:  Report  of  a  Clinic,"  by 
William  R.  P.  Emerson,  M.D. 

20.    "How  to  Organize  a  Local  Nutrition  Center." 

24. t  "The  Essentials  in  Diet  for  Good  Nutrition,"  by  Prof. 
E.  V.  McCollum. 

26.  "Weight  and  Height  in  Relation  to  Malnutrition,"  by 
William  R.  P.  Emerson,  M.D.,  and  Frank  A. 
Manny. 

*  Out  of  print. 
t  In  preparation. 

The  serial  numbers  omitted  have  either  been  super- 
seded by  other  pamphlets,  or  the  material  covered  has 
been  ineorporated  in  the  chapters  of  this  book. 


INDEX 


An  asterisk  attached  to  a  number  denotes  that  an  illustration 
of  the  subject  will  be  found  on  or  facing  the  page  indicated- 


Absorption,  84,  107-08,  242- 
44 

Activities  outside  school,  87, 
270;  see  also  Forty- 
eight  hour  list  of  ac- 
tivities 

Actual  weight  line,  see 
Weight  chart 

Adenoids  and  tonsils,  29, 
30,*  34,  148-49,  165, 
218,  259,  267 

Age  and  defect,  see  Defects 
at  various  ages 

Age  and  height,  see  Height 
and  age 

Age  and  weight,  see  Weight 
and  age 

Air,  see  Bad  air.  Open  air. 
Indoor  air 

American  Red  Cross,  At- 
lanta, xvi 

Anaphylaxis,  34,  121,  170- 
71 

Animals,  care  of,  81 
feeding  of,  121-22 

Appetite,  117-19 

Assimilation,  see  Absorp- 
tion, Digestion 

Athletics,  136,  142-43;  see 
also  Camp  life,  Ex- 
ercise 

333 


Atlanta,  Georgia,  xvi,  284 
Average  weight,  see  Weight 

standards 
Average    weight    line,     see 

Weight  chart 


Bad  air,  viii,  xi,  125*;  see 
also  Sleeping  condi- 
tions 

Balanced  diet,  see  Diet,  bal- 
anced 

Bathing,  132 

Bed-wetting,    see    Enuresis 

Beef  juice,  112 

Berkeley  Infii-mary,  Boston, 
xi,  290,*  299 

Blanks,  see  Forms  and 
blanks 

Boas,  Franz,  309 

Borderline  cases,  16-17,  284- 
87 
mental,  49 

Boston,  Mass.,  vii,  xv,  284, 
293-94;  see  also 
Berkeley  Infirmary, 
Little  Wanderers' 
Home,  Massachusetts 
General  Hospital,  and 
names  of  other  Bos- 
ton organizations 


INDEX 


Boston  Dispensary,  vii 

Boston  Tuberculosis  Associ- 
ation, XV,  299 

Bowditeh,  H.  P.,  309 

Boy  Scouts,  66,  137,  261, 
272 

Breakfast,  85,  95-96,  119, 
247 

Breathing,  obstructions  to, 
see  Naso-pharyngeal 
obstiniction 

Bureau  of  Educational  Ex- 
periments, New  York, 
xiv,  32  n. 

Burger,  Fred,  311 

Burk,  F.  L.,  309 


California,  xvii 

Calories,  table  of,  100-06 

Camp  life,  119,  140-42,  226, 
252-55 

Candy,  23,  34,  113*-14 

Cardiospasm,  case  of,  224* 

Case  history,  21-24,  37-39, 
52-54;  see  also  List 
of  illustrations 

Cereals,  52,*  109,  111,*  176, 
278 

Chicago,  111.,  XV,  34,*  141,* 
254,*  260,*  284,  291,* 
294^96 

Child's  own  interest,  viii, 
68,  183-86,*  211;  see 
also  Training  for 
health 

Class  method,  vii,  183,  191- 
92;  see  also  Nutri- 
tion class 

Cleveland,  0.,  xvi,  296 


Climate,  10,  97 

Clinic  organization,  see 
Hospital  organiza- 
tion. Nutrition  clinic 

Clinical  evidence,  of  malnu- 
trition, 7,  28 
of  mental  defect,  44 
of  normal  weight,  7,  8* 
of  overweight,  19,  156 

Clothing,  130-31 
weight  of,  table,  310 
See  also  Shoes 

Clubs,  66,  87,  270 

Cocoa,  171-72 

Coffee,  see  Tea  and  coffee 

Community  organization, 
256-65 ;  see  also 
School  conditions 

Competition,  spirit  of,  76, 
86,  183 

Constipation,  129,  172-73 

Contagious  diseases,  23, 147- 
48,  167,  275-76,  280 

Cooking,  X 

Corrective  exercises,  137-38 

Crum,  F.  S.,  147  n. 

Cutaneous  proteid  test,  34, 
171,  330 


Dancing,  88,  136 
Dartmouth  College,  xvii 
Da\ddsohn,  H^  280 
Dayton,  0.,  285 
Defects,  25,  27-28,  40* 

at  various  ages,  34,  148- 
49 

brought  out  by  examina- 
tion, 34,*  37-41 

defined,  167 


334 


INDEX 


Defects  in  overweight  and 
underweight  com- 
pared, 156-58 
See  also  Makiutrition, 
signs  of,  Medical  de- 
fects. Mental  defects, 
Naso-pharyngeal  ob- 
struction, Physical 
defects,  Postural  de- 
fects, Teeth  defects 

Deformity,  34* 

Diagnosis  of  malnutrition, 
see  Case  history, 
Mental  examination, 
Physical-growth  ex- 
amination. Social  ex- 
amination 

Diagnostic  clinic,  see  Nutri- 
tion clinic 

Diet,    viii-ix,    107-22,    151, 
191,  198,  246,  289* 
balanced,  109-10 
in  overweight,  160-61 
See       also       Absorption, 
Food,  Measured  feed- 
ing 

Digestion,  96-97,  170-71, 
see  also  Absorption 

Diphtheria,  147 

Diploma,  190* 

Drafts,  128,  200,  278 

Drugs,  16,  118,  128-30,  151, 
171-72 

Duodenal  bands,  case  of, 
28,*  219-20 


Employment  certificates, 
candidates  for,  141,* 
2M*-55,  257,  260* 


Endocrine  glands,  see  Glands 

Enuresis,  173-74 

Essentials  of  health,  ix,  5, 
63-68 

Examination,  see  Mental  ex- 
amination, Physical- 
growth  examination, 
Social  examination 

Exercise,  63,  134-45,  253-54 
for  overweight,  161 
See  also  Gymnastics 

Extension  service,  260-61 


Family  history,  22 
table,  116 
types,  49,  201-04 
Fast  eating,  115-16 
Fathers'  and  Mothers'  Club, 

Boston,  XV 
Fatigue  limit,  80-81,  143-44 
posture,  8,  28 
See  also  Overfatigue 
Fears,  72,  75-76,  276,  278 
Fisher,   Irving,   xi,   91,   273 

n.,  274  n. 
Fisk,  E.  L.,  274  n., 
Focal  infection,  31 
Food,    amount    needed,    90, 
96,  99,  107 
aversions,  119-21,  171 
exhibit,  92* 

habits,  ix-xi,  xiii,  23,  55, 
70*,  93,  107-22,  151- 
52,  270 
poisoning,    see    Anaphy- 
laxis 
values,  90-92 
in  100  calory  portions, 
table  of,  100-106 


335 


INDEX 


Foods  essential  to  growth, 
110 

Forms  and  blanks,  311-325, 
331 

Forty-eight  hour  diet  list, 
92,  108-09,  186 

Forty-eight  hour  list  of  ac- 
tivities, 51,  82-83 

Foster  homes,  57*-58,  250- 
52 

"Free  to  gain,"  8,  67,  234 

Fresh  air,  see  Open  air 

Fruit,  112,  176 


Gain,  see  Group  gains.  In- 
dividual   gains.    Per- 
centage, actual,  of  ex- 
pected gain 
Games,  134-36,  138 
Girl   Scouts,   66,   137,   261, 

272 
Glands,  endocrine,  159 
enlarged,  29,  165-66 
Glossary,  326-30 
Graduation,  20,  186,  190 
Grand   Rapids,   Mich.,   xvi, 

292,*  296-97 
Greeley,  R.  L.,  xiii 
Group    gains,    141,*    289*- 

92,*  299 
Growth,  16-17,  82 
rapid  initial,  7,*  10 
rate  of,  10 
table,  308 
seasonal,  139 

See  also  Group  gains, 
Height,  Individual 
gains,  Malnutrition 
and     growth.     Over- 


weight, Percentage 
actual  of  expected 
gain,  Physical-growth 
examination.  Stunt- 
ing, Underweight 
Gymnastics,  136,  235;  see 
also  Corrective  exer- 
cises; Setting-up  ex- 
ercises 


Habit,     see     Food     habits, 

Health  habits,  Regu- 

laiity 
Habitual    underweight,    see 

Underweight,     habit- 
ual 
Hawaiian  Islands,  xvii 
Health  education,  153,  224, 

227,    239-40,    245-46, 

256,  279-81,  300 
Health,    essentials    of,    see 

Essentials  of  health 
habits,   xiii,  23,  55,  123- 

33,  151-52,  271 
training  for,  see  Training 

for  health 
Hebrew,  lessons  in,  88 
Height  and  age,  12-13,  18,* 

20 
table  of,  306-07 
Height     and     weight,     see 

Weight  and  height 
Height,    how    to    measure, 

16,*  19 
Heredity,  viii,  x-xii,  6,  16, 

20,*  52,*  161 
Hess,  A.  F.,  177  n. 
History,    see    Case   history, 

Family  history 


336 


INDEX 


Holt,  L.  E.,  309 
Home  conditions,  ix,  55,  66 
control,   xiii,    69-79,   150, 
209-10,    213,    218-19, 
267-68,  299-300 
visits,  xi,  189,  198-201 
Hospital    organization,    38, 
40-41,  223-24,  258-59 


Illinois,  285;  see  also  Chi- 
cago 

Increase  in  weight,  see 
Group  gains.  Growth, 
rate  of,  Individual 
gains.  Percentage,  ac- 
tual, of  expected  gain 

Individual  gains,  7,*  9,* 
18,*  185,*  260,*  288,* 
300 

Indoor  air,  125-28 
amusements,  138 

Infant  care  not  continued, 
3,  146,  274-75 

Infection,  see  Contagious 
diseases.  Focal  infec- 
tion.  Sinus  infection 

Initial  gain,  see  Growth, 
rapid  initial 

Institutions,  249-52,  299-300 

Interest,    child's    own,-   see 
Child's  own  interest 
in  children,  204-05 

Internal  secretions,  see 
Glands,  endocrine 

International  Child  Welfare 
Conference,  xv 


Joslin,  E.  P.,  158 


Labrador,  xvii,  285,  297-98 
Lack  of  home   control,  see 

Home  control 
Laxatives,  129,  151 
Liquids,  114;  see  also  Milk, 

Tea  and  coffee.  Water 

drinking 
Little     Wanderers'     Home, 

Boston,   XV,   126-27*, 

149,  284 
Lunches,    see    Mid-morning 

and       mid-afternoon 

lunches,        School 

lunches 


McCoUum,  E.  V.,  120,  178, 

332 
McCoi-mick,   Elizabeth,  Me- 
morial  Fund,    Chica- 
go, xv-xvi,  34*,  141* ; 
see  also  Chicago 
Malnutrition     and     growth, 

3-11 
Malnutrition    and    tubercu- 
losis, 266-72 
Malnutrition,  causes  of,  viii- 
xiii,  xix,  4-6,  10,  71, 
123,  223 
defined,  6 

effects  of,  6,  228-29 
extent  of,  xviii,  3-4,  230, 
282-87 
table,  284-87 
how  to  identify,  12-20 
rule  for   determining,  14 
signs  of,   6-8,   28-29,  43- 

44,  130 
See  also  Defects,  Under- 
weight 


337 


INDEX 


Manchester,  N.  H.,  285 

Manny,  F.  A.,  xiv,  332 

Massachusetts  General  Hos- 
pital, Boston,  XV,  40*, 
149 

Mastication,  114 

Masturbation,  viii,  xii,  72- 
73 

Measles,  147-48,  167 

Measured   feeding,   xi,    89- 
106 
the     remedy     for     over- 
weight, 159-60 

Measuring  height,  16*,  19 

Meat,  112  _ 

Medical  care,  67-68 
defects,  32-34 

Mendel,  L.  B.,  15 

Mental   defects,    22-23,    43- 
50,  202,  205 
examination,  43-50 
fatigue,  143 
tests,  47-48 

Metabolism,  see  Absorption, 
Digestion 

Mid-morning  and  mid-after- 
noon lunches,  98, 189, 
242-43* 

Milk,  52*,  108,  110-12,  115 
amount  needed,  175 

Mineral  salts,  110 

Morbidity  statistics,  273-74 

Mortality  statistics,  147,  273 

Mothei-s,  work  with,  153, 
209-13 ;  see  also 
Home  control,  Par- 
ents 

Mouth  breathing,  28-29 

Mudge,  G.  G.,  191  n. 

Music  lessons,  88 


Naso-pharyngeal  obstruc- 
tion, 29,  67,  148-49; 
see  also  Adenoids  and 
tonsils,  "Free  to 
gain,"  Sinus  infec- 
tion 
New   Hampshire,    xvi;    see 

also  Manchester 
New  York   City,  xiv,  285, 

298 
New  York  Association  for 
Improving  the  Condi- 
tion    of    the     Poor, 
xiv 
Nutrition  camp,  141*,  225- 
26,       251-54*,     257, 
260*,  292* 
class,  vii-viii,  65,  183-92, 
208-14 
for     pre-school     child, 

152,  154 
report    of    a    meeting, 
215-21 
clinic,      222-27,      233-34, 
258-59 
Nutrition   Clinics  for  Deli- 
cate Children,  Incor- 
porated, XV,  331 
Nutrition   institutes,   xv-xvi 
program,  xiii 
outlined,  11 
for  adults,  261-62 

in  camp,  141*-42,  252- 

55 
in  institutions,  249-50 
in    the   school,    230r33, 
240,  257 
worker,  186,  193-206,  207- 

09 
See  also  Malnutrition 


338 


INDEX 


Obesity,  see  Overweight 

Object  lessoii,  use  of,  188, 
210* 

Obstructions  to  breathing, 
see  Naso-pharyngeal 
obstruction 

Open  air,  124, 134, 139, 144, 
268 

Open.-air  schools,  124,  188, 
234 

Outside  activities,  see  Activ- 
ities outside  school 

Overfatigue,  xiii,  43,  45,  54, 
80-88,  144,  150,  229, 
253-54 
cases    of,    52-54,    216-21, 

236*,  247,  268-70 
See    also    Exercise,    Fa- 
tigue,     Play,      Rest, 
School  Program 

Overweight,  19-20*,  155-62* 

Overwork,  144-45 


Parallelogram      of     forces, 

64* -65 
Parents,  25,  186,  193,  195, 
227,  234,  240 

inspection  by,  24,  27 

presence  of,  21,  187,  224- 
26,  228,  230,  247 

responsibility  of,  67,  78, 
226-27 

See  also  Home  control. 
Mothers 
Percentage,  actual,  of  ex- 
pected gain,  formula 
and  table,  298-98; 
see  also  Group  gains, 
Individual  gains 


Percentage  of  underweight, 
see  Borderline  cases. 
Seven  per  oent  un- 
derweight test,  Ten 
per  cent  underweight 
test 

Physical  defects,  xiii,  41*, 
67,  148-49,  209,  267; 
see  also  Defects, 
"Free  to  gain" 

Physical-growth  examina- 
tion, 25-42,  144,  276, 
320* 

Physical  unfitness  in  Anny, 
xviii,  4 

Physician,  xvii-xviii,  195-96, 
208-14,  233 

Pictures  before  and  after 
treatment,  41-42,  44*, 
184*,  186* 

Pirquet,  von,  test,  xii,  33, 
330 

Play,  82,  134-35 

Postural  defects,  137-38 

Posture,  fatigue,  see  Fa- 
tigue posture 

Poverty,  viii-ix,  6 

Pre-school  age,  136,  146-54 

Pi-eventive  medicine,  xvii, 
257,  273-81 

Price,  Minnie,  191  n. 

Problem  cases,  28*,  196, 
219-20,  222-24*,  258 

Program,  see  Forty-eight 
hour  list  of  activities, 
Nutrition  program, 
Summer  program 

Proteid,  111-12 
test,   see   Cutaneous  pro- 
teid test 


339 


INDEX 


Ptosis,  see  Visceroptosis 
Publications,  list  of,  331-32 
Punishment,  77-78 


Reading,  70,  138 
in  bed,  52-53,  247 

Records,  see  Forms  and 
blanks 

Recreation,  134-45 

Regularity,  85,  117,  122, 
133,  270 

Religious  exercises,  66,  87 

Reports,  see  Forms  and 
blanks 

Rest,  83,  133,  168,  188,  220- 
21,  268,  278 
periods,  83-84*,  169,  189, 

235 
See      also      Overfatigue, 
Sleep 

Results,    189-91,    204,    244, 
249-50,  275,  282-301 
table  of,  293-98 
See  also  Group  gains,  In- 
diWdual  gains 

Retardation,  see  Mental  de- 
fects, Stunting 

Rochester,  N.  Y.,  xvi,  259- 
60,  285 

Roentgen-ray,  see  X-ray 

Rose,  M.  S.,  191  n. 

Rule  for  determining  mal- 
nutrition, see  Malnu- 
trition 

St.  Anthony,  Labrador,  285, 

297-98 
Sand,  Ren6, 123 


340 


Scarlet  fever,  147,  167,  275 

Schedules,  typical,  52-54 

School    conditions,    66,    86- 
87,     228-40,     244-45, 
271-72 
examinations,  231* 
hours,  234-39 
lunches,  241-48 
progi-am,  153-54,  217*-18, 

235-39,  291* 
See  also  Open-air  schools 

Seasonal  growth,  see 
Gx'owth,  seasonal 

Self -abuse,  see  Masturba- 
tion 

Setting-up  exercises,  145 

Seven  per  cent  underweight 
test,  14,  284-88 

Sex  habits,  72-73 

Shoes,  131 

Signs  of  malnutrition,  see 
Malnutrition,  signs  of 

Sinus  infection,  31 

Skilton,  Mabel,  xiii,  xix 

Skin  test,  see  Cutaneous 
proteid  test 

Sleep,  amount  needed,  83, 
168-69 

Sleeping  conditions,  55,  56, 
85,  124-25*,  128,  130, 
168,  199-200 

Sleeping  out,  124,  139;  see 
also  Window  tent 

Smedley,  F.  W.,  309 

Smoking,  118 

Social  examination,  51-59, 
197;  see  also  Case 
history,  Home  condi- 
tions 

Soup,  thin,  93-94*;  278 


INDEX 


"Spoiled  child,"  46,  73,  75,  Toronto,  Canada,  285 

140  Training  for  health,  70-71; 

Sports,  see  Athletics  see  also  Child's  own 

Stars,  colored,  187  interest 

Stearns,    A.    Warren,    48,  Tuberculosis,  viii,  xii,  6,  33, 

332  126*-27*,  166-67,  266- 

Story-telling,  85  72,  280 
Stunting,  9*-10,  15-16,  70, 

154 

Suggestion,  influence  of,  70,  Understanding  bet-wreen  par- 

72,  75  ents  and  children,  71- 

Summer    camp,    see    Camp  12,  145 

life  Underweight,  habitual,  15 

program,  138-39  handicap  of,  144 


Sunlight,  124 

Sweets,    98,    114;    see   also 

Candy 
Swunming,  132,  247-48,  254 
Syphilis,  viii,  xii,  6,  16,  22, 

32 
Statistics,  see  Tables 


lowers     resistance,     164, 

276 
See  also  Borderline  cases. 
Malnutrition,     Seven 
per  cent  underweight 
test.     Stunting,     Ten 
per  cent  underweight 
test.      Weight      and 
height 
Tables,  38,  99,  100-06,  149,      Unhappiness,  57*,  117 
157,  177,  284-87,  293- 
98,  305-08 
Tea  and  coffee,  34,  118,  171,      Vacations,  86,  139 

248  Vegetables,  109,  112,  176 

Teachers,  229  Visceroptosis,  28 

Teeth,  care  of,  130  Visitors,  196 

defects,  31-32,  166  Visits  to  homes,  see  Home 

grinding  of,  169  visits 

Temperature,  indoor,  125-28      Vitamins,  107-08,  110,  112, 

test,  33  175-79 

Ten   per   cent   underweight  table  of,  177-78 

test,  14,  284-88 
Thyroid,  16,  159 

Tonics,  97,  129  Walking,  136 

Tonsils,   see   Adenoids   and      Walpole,    Mass.,    xvi,    286, 
tonsils  298 

341 


INDEX 


Washing  down  food,  114-15 
Washington,  D.  C,  287 
Wassermann    test,    xii,    32, 

330 
Water  drinking,  114,  130 
Weighing,  19 
Weight  and  age,  12 
Weight  and  height,  13,  20 
Weight  chart,  vii,  20,  153, 
205,  254 
as  test  of  condition,  152, 

154,  282 
described,  184-86,  319-20 
Weight,  ideal,  17 
standards,   12-13,   174-75, 

309 
tables,  13,  305-10 


See  also  Group  gains,  In- 
dividual gains,  Over- 
weight, Underweight 
Wet  feet,  131-32 
Whooping  cough,  147, 167 
Williamstown,  Mass.,  287 
Window  tent,  xi 
Wood,  Mrs.  I.  C,  xv 
Working  conditions,  144-45, 

255,  260* 
World  War,  4,  15, 123,  135, 

280 
Worry,  117 
Worms,  170 


X-ray  test,  33-34,  330 


(2) 


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